WS Form 12B work Initation Document for Wildlife Damage Management o

OMB Control No. 579-XXXX
1. ______________________________________

2. ________/_________/_________

UNITED STATES DEPARTMENT OF AGRICULTURE

Work Initiation
Document #

ANIMAL AND PLANT HEALTH INSPECTION SERVICE

MM

DD

YY

SECTION 1

WILDLIFE SERVICES
WORK INITIATION DOCUMENT FOR WILDLIFE DAMAGE MANAGEMENT
(Multiple Resource Owners)
3. TYPE OF WORK INITIATION DOCUMENT (mark all that apply):

9 Private Property
9 Non-Private Property

9 Temporary
9 Urban

5. WS Employee and Work
Location Information

6. Land Class Information
Land Class
Acres

7. Adjoining Property
Information Document #

WS Employee Name

1______________ _____________

1_______________________

2. ________________________________

_______________

2. _____________ _____________

2. ______________________

3. ________________________________

3. _____________ _____________

3. ______________________

4. _____________ _____________.

4. ______________________

SECTION 2

_______________
Other WS Employee

_______________

SEC 3

9 Amendment to Existing Work Initiation Document
9 Special Considerations (see Section 6 below)

Total Acres

8. Species Information
1. ________________________________

County
______________________
State

SECTION 4

9 Continuation Form
9 Addendum on File

__________________

4. ________________________________
5. ________________________________

9 Addendum attached for other species

4a. Common Name of Property Allotment_____________________________________________________________b. _______________________
Allotment #
9. Components allowable on this project:
COMPONENTS: a. ____________________________ b.
d.__________________________________________

_ ______ c.__________________________________

e,._____________________________________f.________________________________.

GIf box is marked, an attached WS Form 12B Addendum lists additional components
10.
a. Resource Owner’s Name ___________________________________________________________________
Resource Owner’s Address _________________________________________________________________________________________
Street
_________
State

_____________________
Zip Code

City
______________
Area Code

-

___________________
Telephone Number

b. Resource Owner’s Name ___________________________________________________________________
Resource Owner’s Address _________________________________________________________________________________________
SECTION 5

Street
_________
State

_____________________
Zip Code

City
______________
Area Code

-

___________________
Telephone Number

c. Resource Owner’s Name ___________________________________________________________________
Resource Owner’s Address _________________________________________________________________________________________
Street
_________
State

_____________________
Zip Code

City
______________
Area Code

-

___________________
Telephone Number

d. Resource Owner’s Name ___________________________________________________________________
Resource Owner’s Address _________________________________________________________________________________________
Street
_________
State

_____________________
Zip Code

City
______________
Area Code

-

___________________
Telephone Number

SECTION 6

11. SPECIAL CONSIDERATIONS:

WS FORM 12B

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0579-XXXX. The time required to complete this information
collection is estimated to average .038 minutes/hours per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information.

Instructions For Completing WS Form 12 B – Work Initiation Document for Wildlife
Damage Management (Multiple Resource Owners)
This form is used to obtain information about an agreement in which multiple resource owners
are involved.
SECTION 1 – Document Initiation Information
1

Enter the Work Initiation Document number assigned

2

Enter the current month, day, and year as mm/dd/yy

3

Identify the type(s) of agreements that apply to the control of wildlife damage on nonprivate property. Mark all boxes that apply

SECTION 2 – Property Name and Allotment Number
4

a. Enter the common name of the property or allotment. b. Enter the allotment number
if this is an allotment project.

SECTION 3 – WS Employee, Property, and Species Information
5

Enter only employee’s name. If another employee will be assisting, that name may also
be entered in this section. Enter the state and county for this work initiation.

6

a. Enter all land classes which apply to this agreement with the associated acreage for
each. b. Calculate a total for all acreages in “a” and enter that amount in these blocks.

7

If this Work Initiation Document includes doing work on adjoining properties to address
the damage problem on the primary property, list each document number for each
additional property in this subsection.

8

List the names of the species to be targeted on this agreement. If additional species need
listing, attach a WS Form 12B Addendum and mark the box at the bottom of this block.

SECTION 4 – Components Allowed
9

List all components to be used. If additional components need listing, attach a WS Form
12B Addendum and mark the box at the bottom left of this block.

SECTION 5 – Resource Owner Information
10

a-d - List all resource owners for which this agreement applies with addresses and
telephone numbers for each.

SECTION 6 - Special considerations and cooperator information
11

Record any special considerations agreed upon for this project.

Distribute copies in accordance with instructions from your supervisor.

________________________
Work Initiation
Document #

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
WILDLIFE SERVICES
ADDENDUM TO A WORK INITIATION DOCUMENT

________/________/_______
MM

DD

YY

1. In the document # boxes provided above, enter the number of the Work Initiation Document for which this
addendum is completed.
2. Enter the date the addendum is completed in the date boxes above. Enter as MM-DD-YY.
3. Enter additional species that will be addressed and additional components to be used in the spaces provided below.
4. Obtain signature of Cooperator with date signed
5. Provide copies for each copy of the Work Initiation Document

Additional Species
1. ________________________________

9. ________________________________

17._______________________________

2. ________________________________

10. _______________________________

18. _______________________________

3. ________________________________

11. _______________________________

19.________________________________

4. ________________________________

12.________________________________

20.________________________________

5. ________________________________

13. _______________________________

21.________________________________

6. ________________________________

14,________________________________

22.________________________________

7.________________________________

15.________________________________

2.3________________________________

8. ________________________________

16.________________________________

24. _______________________________

1. ________________________________

9. ________________________________

17._______________________________

2. ________________________________

10. _______________________________

18. _______________________________

3. ________________________________

11. _______________________________

19.________________________________

4. ________________________________

12.________________________________

20.________________________________

5. ________________________________

13. _______________________________

21.________________________________

6. ________________________________

14,________________________________

22.________________________________

7.________________________________

15.________________________________

2.3________________________________

8. ________________________________

16.________________________________

24. _______________________________

Additional Components to Be Used

Cooperator Signature ________________________________________ Date________________________
WS Employee Signature _____________________________________ Date________________________

WS Form 12B - Addendum

Privacy Act Notice
Title 5. United States Code, Section 552a(e)(3) requires that each agency that maintains a system of records provide each individual from whom the
agency solicits information with the following information.
Authority for Requesting Information
Title 7, United States Code (USC), Section 426-426c, and Title 16 USC, Section 667, authorizes officers, agents, and employees of the USDA,
APHIS, Wildlife Services to conduct a program of wildlife services and to enter into agreements with States, local jurisdictions, individuals, and
public and private agencies, organizations, and institutions for the purpose of conducting such services. Further, 5 USC 552a authorizes USDA,
APHIS, Wildlife Services to collect information about private individuals for its system of records pursuant to the conduct of program activities with
those private individuals.
Nature of Your Disclosure of Information
Disclosure of information solicited by USDA, APHIS, Wildlife Services is voluntary.
Principle Purpose for Which the Information is Solicited
Information is solicited from you for the purpose of executing and implementing agreements for control of wildlife damage.
Routine Uses Which May be Made of the Information
The routine uses which may be made of the information are:
Routine use 1 provides for disclosure to the cooperative State government officials, employees, or contractors, as necessary to carry out the program.
Routine use 2 provides for the referral to the appropriate agency, whether Federal, State, local, or foreign, charged with responsibility of
investigating or prosecuting a violation of law or of enforcing, implementing, or complying with a statute, rule, regulation, or order issued pursuant
thereto, of any record within this system when information available indicates a violation or potential violation of law, whether civil, criminal, or
regulatory in nature, and either arising by general statute or particular program statute, or by rule, regulation, or court order issued pursuant thereto;
Routine use 3 permits disclosure to the Department of Justice when the Agency, or any component thereof, or any employee of the Agency in his or
her official capacity, or any employee of the Agency in his or her individual capacity where the Department of Justice has agreed to represent the
employee, or the United States, in litigation, where the Agency determines that litigation is likely to affect the Agency or any of its components, is a
party to litigation or has an interest in such litigation, and the use of such records by the Department of Justice is deemed by the Agency to be
relevant and necessary to the litigation; provided, however, that in each case, the Agency determines that disclosure of the records to the Department
of Justice is a use of the information contained in the records that is compatible with the purpose for which the records were collected;
Routine use 4 permits disclosure for use in a proceeding before a court or adjudicative body before which the Agency is authorized to appear, when
the Agency, or any component thereof, or any employee of the Agency in his or her official capacity, or any employee of the Agency in his or her
individual capacity where the Agency has agreed to represent the employee, or the United States, where the Agency determines that litigation is
likely to affect the Agency or any of its components, is a party to litigation or has an interest in such litigation, and the Agency determines that use of
such records is relevant and necessary to the litigation; provided, however, that in each case, the Agency determines that disclosure of the records to
the court is a use of the information contained in the records that is compatible with the purpose for which the records were collected;
Routine use 5 permits disclosure to a congressional office in response to a request from that office for the record of an individual made at the request
of that individual;
Routine use 6 permits disclosure to the Comptroller General or any of his authorized representatives in the course of their duties at the Government
Accountability Office; and
Routine use 7 permits disclosure to a consumer reporting agency in accordance with section 31 U.S.C. 3711(e).
Routine use 8 permits disclosure to appropriate agencies, entities, and persons when the Agency suspects or has confirmed that the security or
confidentiality of information in the system of records has been compromised; the Agency has determined that as a result of the suspected or
confirmed compromise there is a risk of harm to economic or property interests, a risk of identity theft or fraud, or a risk of harm to the security or
integrity of this system or other systems or programs (whether maintained by the Agency or another agency or entity) that rely upon the
compromised information; and the disclosure made to such agencies, entities, and persons is reasonably necessary to assist in connection with the
Agency’s efforts to respond to the suspected or confirmed compromise and prevent, minimize, or remedy such harm.
Effects of Failure to Furnish Information
Failure to provide the solicited information will not subject you to penalties or adverse consequences.