WS Form 35 Report of Injury or Death of Nontarget Animal

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not 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 0579-0335. The time required to complete this information collection is estimated to average .38 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.

OMB Approved 0579-0335 EXP XX/XXXX

United States Department of Agriculture Animal and plant health inspection service Wildlife services Report of injury or dealth of nontarget animal

instructions: This form is for use as directed by supervisor following the injury or death of domestic animals or threatened/endangered species by WS equipment or actions. Complete all applicable items; additional questions are on reverse side of this form. Attach additional sheets as necessary. Attach statements of witness, photocopy of agreement, map of location and photos of sites and animal if possible.

1. description of animal

2. domestic animal discovery information

A. Species

B. Breed (if Applicable)

C. Estimated Weight

D. Age Class

E. Sex Male Female

A. Did Owner Contact WS? Yes No

B. Value of Animal (If known) $

C. Who found Animal? (Optional)

D. Contact Information-Optional (Address or phone)

3. name of owner of animal

4A. Accident Location (nearest city/town, ranch or highway intersection or GPS Coordinators, or Township-Range-Section if authorized) GPS coordinates _______________ township/range/section _______/______/________ County/parish _______________________________state _____________________________

Street Address/P.O. Box

City/Town

4B. land class Private BLM USFS State Other

Name of Property Owner or Land Managing Office

State

ZIP Code

Phone Number ( )

Street Address/P.O. Box

4C. land operator (Lessee) Name and Address

City/Town

State

ZIP Code

Phone Number ( )

5. death/injury

Indicate disposition of animal Injury Death

Date of injury or death

Cause: (If injury, describe)

6A. was autopsy conducted or sample tested for toxic material Yes No

6B. by whom

6C. findings

7. was owner aware of control work in area Yes No

8. Did animal belong to owner or lessee of property where control work was being done Yes No

9. Was agreement current Yes No

10. was control site properly posted with signs in readable condition Yes No

11. name of employee conducting control work

12. steps taken to prevent recurrence

Report of incident: Attach additional sheets as necessary. Attach statements of witnesses, photocopy of agreement, map of location and photos of site and animal if possible.

13. in cases involving threatened and endangered (t&e) species note signicance of loss to local/national population was t&e species previously known to exist in area? Yes No

chemical

14. type

15. strength

16. registration number

17. carrier bait

18. symptoms evident

19. time elapsed from ingeston to symptoms/death

20. animal’s proximity to toxocant

mechanical

21. type

22. Describe set

23. estimated time animal in equipment

23. date of last equipment check

24. nature and purpose of control work being conducted (i.e., depredation request, rodent control, etc.)

WS FORM 35

FEB 2011

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, Section 426-426c, and Title 16 United States Code, 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.

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.