Form 3-202-4 Rehabilitation Annual Report

U.S. FISH & WILDLIFE SERVICE - MIGRATORY BIRD PERMIT OFFICE
(See attached addresses)
REHABILITATION ANNUAL REPORT - REPORT YEAR ___________
Report Due: ___________
PERMITTEE:

PERMIT NUMBER:_________________

ADDRESS:

PHONE NUMBER: ______________________________________

E-Mail: _____________________________________________________
City
State
Zip Code
 Check here if reporting a change of name, address, or contact information

INSTRUCTIONS: Please type or print the information requested below for all migratory birds (see 50 CFR 10.13) held under your permit
during the report year, and return the completed report to the above address by January 31 of the following year. Use of this form is not
mandatory, but the same information must be submitted. A supplemental sheet is available if needed. Do not include species other than migratory
birds in your report. Filing an annual report is a condition of your permit. Failure to file a timely report could result in suspension of your permit.
You must submit a report even if you had no activity during the year. Make sure you sign the certification at the end of the form. (Ref. 50
CFR parts 13 & 21)
DISPOSITION CODES: R=Released; T=Transferred; P=Pending; E=Euthanized; D=Died; DoA=Dead on Arrival
A. NEW ACQUISITIONS. Please provide a summary of all birds acquired during the report year, categorized by species. The quantity in the
Received column should equal the sum of the quantities in the Disposition column. (For example: Robins: 14 - 10, 0, 1, 2, 1). Also complete

sections B and D for Pending and Transferred birds, respectively. All birds, including birds reported in C, D, and E, must be reported here.
Please enter any Bald Eagle or Golden Eagles first.
Common Name

Total Number
Received

Released

Transferred

Disposition (enter quantity)
Euthanized
Pending

Died

DoA

B. BIRDS HELD 180 DAYS OR LONGER ON 12/31. Please complete for any individual birds that you had held 180 days or longer as of 12/31 of the report
year. Please identify any birds you maintain as foster parents with a circled “F” next to their common name.

Common Name

Date Acquired

Nature of Injury

Proposed Disposition (check one)
R
T
E

CERTIFICATION: I certify that the above information is true and correct to the best of my knowledge. I understand that any false
statement herein may subject me to the criminal penalties of 18 U.S.C. 1001.
Signature:
Form 3-202-4

Rev 9/2010

Continue to next page

Date:
OMB No. 1018-0022

Expires x/xxxxxx

REHABILITATION PERMIT ANNUAL REPORT - YEAR
PERMIT NO.
(Pg. 2)
C. REPORTED INJURIES Please complete for any individual birds received that were shot, poisoned (confirmed), electrocuted,
trapped (e.g., foot-hold), or otherwise injured or killed as the result of a potentially criminal activity, EXCEPT report confirmed internal
contaminant injuries and mortalities in section E . (Such injuries should have been reported immediately.) DISPOSITION CODES:
R=Released; T=Transferred; P=Pending; E=Euthanized; D=Died; DoA=Dead on Arrival.
Disposition (check one)
Date
Cause/Nature
Common Name
Acquired
of Injury
R
T
P
E
D

DoA

Source
(County & State)

D. TRANSFERS. Please complete for individual LIVE birds you transferred during the report year (1/1-12/31). For Permit Number or
Address, provide the permit number if applicable; if not applicable, provide address. For Purpose of Transfer, use the following codes: R =
Released; C = Continued Care; E/S = Education or Scientific Research permit; F/P=Falconry or Raptor Propagation permit; O = Other – please
enter permit type.
Transferred to (Recipient)
Purpose
Common Name
of Transfer
Name
Permit Number or Address
Date

E. OPTIONAL. - DISEASE & CONTAMINANTS. Providing the information requested below is voluntary. Please complete for any
individual birds received that were tested & were confirmed to have died of infectious disease such as West Nile virus (not parasites), or ingested
contaminants such as sodium pentobarbital, carbofuran, or lead. Note: The FWS does not require testing of birds for disease or contaminants
and the following information requirement should not be construed as a recommendation to do so. However, for any birds that you chose to have
clinically tested that resulted in a confirmed diagnosis, please provide the requested information. Do not include data on birds you suspect
succumbed as a result of disease or toxins but were not tested, or birds that were tested but results were inconclusive. Thank you.
Concentration
Tissue Tested
Date
of toxin, or if
Source of Bird
Name of Disease or
(e.g., blood/
Acquirinfectious
Name of Lab
Common Name
(County &
bone/ brain/
Contaminant
ed
disease, test
& State
liver/kidney/ GI
State)
used for
tract contents)
diagnosis

Form 3-202-4

Rev 9/2010

OMB No. 1018-0022

Expires x/xxxxxx

SUPPLEMENTAL SHEET - REHABILITATION ANNUAL REPORT - Year________ PERMIT NO.
__
Page ___
A. NEW ACQUISITIONS. Please provide a summary of all migratory birds acquired during the report year, categorized by species. The quantity
in the Received column should equal the sum quantities in the Disposition columns. (For example: Robins: 14 - 10, 0, 1, 2, 1). Also complete

sections D and E for Pending and Transferred birds, respectively. All birds, including birds reported in C, D, and E, must be reported here.
Common Name

Form 3-202-4

Rev 9/2010

Total Number
Received

Released

Disposition (enter quantity)
Transferred
Pending
Euthanized

OMB No. 1018-0022

Died

Expires x/xxxxxx

DOA

SUPPLEMENTAL SHEET - REHABILITATION ANNUAL REPORT - Year_________ PERMIT NO.
___
Page ____
B or C. Use as additional space for completing sections B or C. Please indicate in the left column the letter of the section that corresponds to the
information you have provided below. DISPOSITION CODES: R=Released; T=Transferred; P=Pending; E=Euthanized; D=Died.
Cause/Nature
Date
Disposition (check one)
Date of Disposition
Acquired
Common Name
of Injury
R
T
P
E
D
DOA

D. TRANSFERS. Please complete for individual LIVE birds you transferred during the report year (1/1 - 12/31). For Permit Number or Address
provide the permit number if applicable; if not applicable, provide address. For Purpose of Transfer, use the following codes: R = Release;
C = Continued Care; E/S = Education or Scientific Purposes; F/P = Falconry or Raptor Propagation permit; O = Other – please enter permit type.
Transferred to (Recipient)
Purpose of
Common Name
Transfer
Name
Permit Number or Address
Date

E. OPTIONAL. - DISEASE & CONTAMINANTS. Providing the information requested below is voluntary. Please complete for any
individual birds received that were tested & were confirmed to have died of infectious disease such as West Nile virus (not parasites), or ingested
contaminants such as sodium pentobarbital, carbofuran or lead. See further instructions in section E on page 2. Thank you!
Concentration
Date
of toxin, or if Tissue Tested
Name of Disease or
(e.g., blood/
AcquirName of Lab
Source of Bird
infectious
Common Name
bone/ brain/
Contaminant
ed
& State
(County & State)
disease, test liver/kidney/ GI
used for
tract contents)
diagnosis

Form 3-202-4

Rev 9/2010

OMB No. 1018-0022

Expires x/xxxxxx

FEDERAL FISH AND WILDLIFE PERMIT REPORT
Paperwork Reduction Act, Privacy Act, and Freedom of Information Act – Notices
In accordance with the Paperwork Reduction Act of 1995 (44 U.S.C. 3501, et seq.) and the Privacy Act of 1974 (5 U.S.C. 552a),
please be advised:
1.
The gathering of information on fish and wildlife is authorized by:
(Authorizing statutes can be found at: http://www.gpoaccess.gov/cfr/index.html and http://www.fws.gov/permits/ltr/ltr.shtml.)
a.
b.
c.
d.
e.

Bald and Golden Eagle Protection Act (16 U.S.C. 668), 50 CFR 22;
Migratory Bird Treaty Act (16 U.S.C. 703-712), 50 CFR 21;
General Provisions, 50 CFR 10;
General Permit Procedures, 50 CFR 13; and
Wildlife Provisions (Import/export/transport), 50 CFR 14.

2.
Information requested in this form is purely voluntary. However, submission of requested information is a condition of your
permit under the above laws. Failure to provide all requested information may be sufficient cause for the U.S. Fish and Wildlife Service
to revoke your permit. We may not conduct and you are not required to respond to a collection of information unless it displays a
currently valid OMB control number. OMB has approved this report and assigned OMB Control No. 1018-0022.
3.
Disclosures outside the Department of the Interior may be made without the consent of an individual under the routine uses listed
below, if the disclosure is compatible with the purposes for which the record was collected. (Ref. 68 FR 52611, September 4, 2003)
a.

b.
c.

d.
e.

f.
g.
h.

Routine disclosure to subject matter experts, and Federal, tribal, State, local, and foreign agencies, for the purpose of
obtaining advice relevant to making a decision on an application for a permit or when necessary to accomplish a FWS
function related to this system of records.
Routine disclosure to Federal, tribal, State, local, or foreign wildlife and plant agencies for the exchange of information on
permits granted or denied to assure compliance with all applicable permitting requirements.
Routine disclosure to Federal, tribal, State, and local authorities who need to know who is permitted to receive and
rehabilitate sick, orphaned, and injured birds under the Migratory Bird Treaty Act and the Bald and Golden Eagle
Protection Act; federally permitted rehabilitators; individuals seeking a permitted rehabilitator with whom to place a bird in
need of care; and licensed veterinarians who receive, treat, or diagnose sick, orphaned, and injured birds.
Routine disclosure to the Department of Justice, or a court, adjudicative, or other administrative body or to a party in
litigation before a court or adjudicative or administrative body, under certain circumstances.
Routine disclosure to the appropriate Federal, tribal, State, local, or foreign governmental agency responsible for
investigating, prosecuting, enforcing, or implementing statutes, rules, or licenses, when we become aware of a violation or
potential violation of such statutes, rules, or licenses, or when we need to monitor activities associated with a permit or
regulated use.
Routine disclosure to a congressional office in response to an inquiry to the office by the individual to whom the record
pertains.
Routine disclosure to the General Accounting Office or Congress when the information is required for the evaluation of the
permit programs.
Routine disclosure to provide addresses obtained from the Internal Revenue Service to debt collection agencies for
purposes of locating a debtor to collect or compromise a Federal claim against the debtor or to consumer reporting agencies
to prepare a commercial credit report for use by the FWS.

4.
For individuals, personal information such as home address and telephone number, financial data, and personal identifiers
(social security number, birth date, etc.) will be removed prior to any release of information.
5.
The public reporting burden on the applicant for information collection varies depending on the activity for which a permit is
requested. The relevant burden for a Rehabilitation permit annual report is 3 hours. This burden estimate includes time for reviewing
instructions, gathering and maintaining data and completing and reviewing the form. You may direct comments regarding the burden
estimate or any other aspect of the form to the Service Information Clearance Officer, U.S. Fish and Wildlife Service, Mail Stop 222,
Arlington Square, U.S. Department of the Interior, 1849 C Street, NW, Washington D.C. 20240.
Freedom of Information Act – Notice
For organizations, businesses, or individuals operating as a business (i.e., permittees not covered by the Privacy Act), we request that
you identify any information that should be considered privileged and confidential business information to allow the Service to meet its
responsibilities under FOIA. Confidential business information must be clearly marked "Business Confidential" at the top of the letter
or page and each succeeding page and must be accompanied by a non-confidential summary of the confidential information. The nonconfidential summary and remaining documents may be made available to the public under FOIA [43 CFR 2.13(c)(4), 43 CFR
2.15(d)(1)(i)].

Migratory Bird Regional Permit
Offices
FWS
REGION

AREA OF
RESPONSIBILITY

MAILING
ADDRESS

CONTACT
INFORMATION

Region 1

Hawaii, Idaho, Oregon,
Washington

911 N.E. 11th Avenue
Portland, OR 97232-4181

Tel. (503) 872-2715
Fax (503) 231-2019
Email [email protected]

Region 2

Arizona, New Mexico,
Oklahoma, Texas

P.O. Box 709
Albuquerque, NM 87103

Tel. (505) 248-7882
Fax (505) 248-7885
Email [email protected]

Region 3

Iowa, Illinois, Indiana,
Minnesota, Missouri,
Michigan, Ohio, Wisconsin

One Federal Drive
Fort Snelling, MN 55111

Tel. (612) 713-5436
Fax (612) 713-5393
Email [email protected]

Region 4

Alabama, Arkansas, Florida,
Georgia, Kentucky, Louisiana,
Mississippi, North Carolina,
South Carolina, Tennessee,
Virgin Islands, Puerto Rico

P.O. Box 49208
Atlanta, GA 30359

Tel. (404) 679-7070
Fax (404) 679-4180
Email [email protected]

Region 5

Tel. (413) 253-8643
Fax (413) 253-8424
Email [email protected]

Connecticut, District of
Columbia, Delaware, Maine,
Maryland, Massachusetts,
New Hampshire, New Jersey,
New York, Pennsylvania,
Rhode Island, Virginia,
Vermont, West Virginia

P.O. Box 779
Hadley, MA 01035-0779

Region 6

Colorado, Kansas, Montana,
North Dakota, Nebraska,
South Dakota, Utah, Wyoming

P.O. Box 25486
DFC(60154)
Denver, CO 80225-0486

Tel. (303) 236-8171
Fax (303) 236-8017
Email [email protected]

Region 7

Alaska

1011 E. Tudor Road
(MS-201)
Anchorage, AK 99503

Tel. (907) 786-3693
Fax (907) 786-3641
Email [email protected]

2800 Cottage Way
Sacramento, CA 95825

Tel. (916) 978-6183
Fax (916) 414-6486
Email [email protected]

Region 8

California, Nevada