Form 3-202-15 Eagle Take Annual Report

U.S. FISH & WILDLIFE SERVICE - MIGRATORY BIRD PERMIT OFFICE
(See attached addresses)
EAGLE TAKE (§ 22.26) - ANNUAL REPORT
PERMITTEE: __________________________________________

PERMIT NUMBER:_______________________________

ADDRESS: ____________________________________________

REPORT FOR CALENDAR YEAR*: ________________
*Programmatic take only
REPORT DUE DATE: _____________________________

_______________________________________________________
City

State

Zip Code

 Check here if reporting a change of name, address, or contact information

PHONE: ___________________________ Email: ______________________________

INSTRUCTIONS: Use section A (pp 1-2) to report eagle observations when monitoring for possible disturbance. Use section B (pp 3-4) to report eagle injuries and
mortality. Type or print the information requested below for each Important Eagle-Use Area (IEUA) identified on your permit during the year covered by this report and return the
completed report to the above address by the due date. Filing an annual report is a condition of your permit. Failure to file a timely and accurate report can result in permit
suspension. Accurate reporting will play an essential role in future eagle management.
Instructions for Section A: Continue data entry for each IEUA on additional Sec A Supplemental Sheet. (You may need to make or print copies of the blank supplemental sheet.)
Use a separate supplemental sheet for each IEUA identified on your permit.
MAKE SURE YOU SIGN & DATE THE CERTIFICATION STATEMENT BELOW BEFORE YOU SUBMIT YOUR REPORT.

A.

IMPORTANT EAGLE-USE AREA:
If more than one of one type of IEUA is identified on your permit, designate which nest (or roost or foraging area) data applies to.
DATE
OBSERVED BEHAVIOR
DESCRIPTION OF HUMAN ACTIVITY
NUMBER OF
TIME
P – perched
IF– in flight
EAGLES
OF DAY
EAGLES
AT TIME EAGLES WERE OBSERVED
F – feeding
AB – agitated
(e.g., surveying; excavation; interior work, etc.)
OBSERVED
OBSERVED
behavior
If activity is completed, enter “Completed”
(If in large numbers, please N – sitting on or
attending
nest
estimate)

CERTIFICATION: I certify that the information in this report 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:
Date: _________________________________
Form 3-202-15

(Rev 9/2010)

OMB No. 1018-0022 Expires XX/XX/XXXX

Section A Supplemental Sheet
EAGLE TAKE ANNUAL REPORT

REPORT YEAR__________

SUPPLEMENTAL PAGE #:____

PERMITTEE:__________________________________

PERMIT NUMBER:__________________

IMPORTANT USE AREA :
Identify nest, communal roost, or foraging area. Use a separate supplemental sheet for each IUA
DATE
EAGLES OBSERVED

Form 3-202-15

TIME
OF DAY

NUMBER OF
EAGLES
OBSERVED
(If in large numbers, please
estimate)

OBSERVED BEHAVIOR
P – perched
F – feeding
N – sitting on or
attending nest

IF– in flight
AB – agitated
behavior

DESCRIPTION OF HUMAN ACTIVITY
AT TIME EAGLES WERE OBSERVED
(e.g., surveying; excavation; interior work, etc.)
If activity is completed, enter “Completed”

OMB No. 1018-0022

Expires XX/XX/XXXX

Section B
INSTRUCTIONS: Instructions for Section B: Use a separate supplemental sheet for each discreet geographic area covered by your permit (e.g. “South tract” or “Clark
County” or “Management Area xxxx.” Continue data entry for each geographic area on an additional Sec B Supplemental Sheet. (You may need to copy or print more blank
supplemental sheets.
MAKE SURE YOU SIGN & DATE THE CERTIFICATION STATEMENT BELOW BEFORE YOU SUBMIT YOUR REPORT

B.

Was this data entered into the USFWS Bird
Injury/Mortality Reporting System (BIMRS)?

GEOGRAPHIC AREA OF REPORTING:
Identify project/activity area
DATE
SPECIFIC
DISCOVERED
LOCATION
(e.g. utility pole #xx)

 YES
SPECIES
Bald or Golden

STATUS OF EAGLE
Use:
“I” for injured,
“D” for dead, or
“C” for uninjured but caught or
trapped in equipment or
infrastructure

 NO

DISPOSITION

ADDITIONAL COMMENTS

Use:
“NER” if sent to the National
Eagle Repository;
“PR” if transferred to
permitted eagle rehabilitator;
“R” if released.

Use this area to provide additional
explanation, if needed, (e.g., name and
permit number of rehabilitator if you
entered “PER” under
“DISPOSITION.”

CERTIFICATION: I certify that the information in this report 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 3-202-15

Date:
OMB No. 1018-0022

Expires XX/XX/XXXX

Section B Supplemental Sheet
Was this data entered into the USFWS Bird
Injury/Mortality Reporting System (BIMRS)?

GEOGRAPHIC AREA OF REPORTING :
Identify project/activity area
DATE
SPECIFIC
DISCOVERED
LOCATION
(e.g. utility pole #xx)

Form 3-202-15

 YES
STATUS OF EAGLE

SPECIES
Bald or Golden

Use:
“I” for injured,
“D” for dead, or
“C” for uninjured but caught or
trapped in equipment or
infrastructure

 NO

DISPOSITION

ADDITIONAL COMMENTS

Use:
“NER” if sent to the National
Eagle Repository;
“PR” if transferred to permitted
eagle rehabilitator;
“R” if released.

Use this area to provide additional
explanation, if needed, (e.g., name and
permit number of rehabilitator if you
entered “PER” under “DISPOSITION.”

OMB No. 1018-0022

Expires XX/XX/XXXX

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 § 22.26 Eagle Take
permit annual report is 30 hours (including monitoring). 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)].