Form 3-202-17 Special Purpose - Utility (Avian Take Monitoring) - Annu

U.S. FISH & WILDLIFE SERVICE - MIGRATORY BIRD PERMIT OFFICE
(See attached addresses)

SPECIAL PURPOSE – UTILITY (AVIAN TAKE MONITORING) - ANNUAL REPORT
PERMITTEE: __________________________________________________________

PERMIT NUMBER:_________________________

ADDRESS: _____________________________________________________________

REPORT FOR CALENDAR YEAR: _______________

Office Use Only
Date Completed
Report rec’d in
Regional Office
______/_____/_____
__
Initials: ________

_____________________________________________________________ REPORT DUE DATE: ___________________________
City
State
Zip Code
Check here if reporting a change of name, address, or contact information
PHONE: _______________________ Email:________________________________
INSTRUCTIONS: Type or print the information requested below for all migratory birds, including eagles, salvaged or recovered under your permit during the report year, and
return the completed report to the above address by the due date. Use of this form is not mandatory, but the same information must be submitted. A supplemental sheet is
available if needed. 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 report year. NOTE: If your permit conditions require report information that is different from that requested below, please provide the
additional information on a separate sheet. MAKE SURE YOU SIGN & DATE THE CERTIFICATION STATEMENT BELOW BEFORE YOU SUBMIT YOUR
REPORT. (Ref. 50 CFR parts 13 & 21)
A. Type of Utility/Equipment/structure potentially causing the injury/mortality:
B.

SPECIES
(Common Name)

Example 1
Golden Eagle
Example 2
Red-tailed hawk

Form 3-202-17

Condi- WHEN & WHERE SALVAGED / RECOVERED
tion
A=
Date State; county; nearest
GPS
Alive or
town or name of facility
coordinates in
D=
decimal degrees
Dead
D

10/7

A

9/1

CO, Lincoln, Hugo

38.889722°, 77.008889°
VA, Prince William, ACME 38.889722°, distribution station
77.008889°

Descrip
tion
C=
Carcass
P=
Parts
A=Alive
C

Apparent
Cause of
Inj./Mortality
E=Electrocution
C=Collision
B=Barotrauma
Other (Specify)
C

Estimated
date of
mortality/
injury

10/6

Weather
conditions when
mortality/injury
likely occurred,
if known (clear,
fog, windy, snow,
rain)
Windy

A

B

8/30

Fog

Disposition
D=Destroyed
(buried, incinerated)
T=Transferred (to
whom/permit no.)
Other (Specify)
T-USFWS/OLE
T-Avian rehab cntr.
MB123456

OMB No. 1018-0022

Expires xx /xx/20xx

SUPPLEMENTAL SHEET - SPECIAL PURPOSE UTILITY ANNUAL REPORT
PERMITTEE:
B.
SPECIES
(Common Name)

Form 3-202-17

PERMIT NUMBER:
Condi- WHEN & WHERE SALVAGED / RECOVERED
tion
Date State; county; nearest GPS coordinates in
A=
town or name of facility decimal degrees
Alive or
D=
Dead

REPORT YEAR: _________
Estimated
Descrip Apparent
tion
Cause of
date of
C=
Inj./Mortality mortality
Carcass E=Electrocution /injury
P=
C=Collision;
Parts
B-Barotrauma;
A=Alive Other (Specify

SUPPLEMENTAL PAGE NO: ____
Disposition
Weather
conditions when D=Destroyed
mortality/injury (buried, incinerated)
likely occurred, T=Transferred (to
if known (clear, whom/permit no.)
fog, windy, snow, Other (Specify)
rain)

OMB No. 1018-0022

Expires xx /xx/20xx

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 or sponsor 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 Special Purpose – Utility Permit annual
report is 2 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 non-confidential 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)].

Form 3-202-17

OMB No. 1018-0022

Expires xx /xx/20xx