Form WS Form 12C WS Form 12C Work Initiation Document for Management of Wildlife Dama

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 .021 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 Work initiation document for Management of Wildlife Damage on Urban Properties

A. County and WS Employee Information: AGR. Type: T C AE AP SC County ________________________ ST _________ Civil Agreement No. __________________________ Land Class __________________ Acres _________ Employee Name _____________________________ Employee Name _____________________________ Employee Name _____________________________ Employee Name _____________________________

B. Mark all Species to Be Managed

C. Mark all approved components to be USED on this project

Striped Skunk

MT. Lion

Opossum

Feral Pigeons

Cage trap

A – Chloralose

Raccoon

E. Starlings

Firearm

(inad Number _________)

Coyote

W-Tailed Deer

Catch Pole

Black Bear

Canada Geese

Rocket/cannon net

Other (list)

Net Gun

Other (list)

Other (list)

Other (list)

Other (list)

D. I, the Cooperator, have been informed of the manner in which the damage management components listed in Section C. will be used, and of the possible hazards associated with their use. I understand that APHIS, to include its officers, employees, and agents will: exercise reasonable precautions to safeguard all persons and to prevent injury to animal life other than those listed in Section B. above; guard against the mishandling of control devices and materials; and exercise due caution and proper judgment in all control operations. In consideration of these understandings and of the benefits to be derived, I, the cooperator, agree: to take reasonable precautions to prevent injury to domestic animals; to assume responsibility for injury to my property or to property under my control, when said injury is not the result of negligence on the part of APHIS; and that no traps should be left actively deployed and unmonitored over weekends or holidays. This work initiation document may be revoked by either party by a 30–day written notice

E. Special Considerations:

F.

Name of landowner, lessee, or administrator

Address and Telephone Number

Date

G.

Signature (Landowner, Lessee, or Administrator)

Address and Telephone Number

Date

H.

Signature and Title (APHIS Representative)

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 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.

Principal 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 permits disclosure to cooperative State government officials, employees, or contractors, as necessary to carry out the program; and other parties engaged to assist in administering the program. Such contractors and other parties will be bound by the nondisclosure provisions of the Privacy Act. This routine use assists the agency in carrying out the program, and thus is compatible with the purpose for which the records are created and maintained;

Routine use 2 permits disclosure to the appropriate agency, whether Federal, State, local, or foreign, charged with the 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/her official capacity, or any employee of the agency in his/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/her official capacity, or any employee of the agency in his/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 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.

Routine use 6 permits disclosure to USDA employees or contractors, partner agency employees or contractors, or private industry employees to identify patterns, trends, or anomalies indicative of fraud, waste, or abuse.

Routine use 7 permits disclosure to the National Archives and Records Administration or to the General Services Administration for records management inspections conducted under 44 U.S.C. §§ 2904 and 2906.

Effects of Failure to Furnish Information

Failure to provide the solicited information will not subject you to penalties or adverse consequences.

WS FORM 12C

MAR 2010

Instructions For Completing WS Form 12C

Work Initiation Document for Management

of Wildlife Damage on Urban Properties

A. County and WS Employee Information:

Enter the agreement type by marking the appropriate box to indicate:

“T” = Temporary, “C” = Continuation Form, “AE” = Amendment of an Existing Agreement, “AP” = Addendum to a Private Agreement, or “SC” = Special Considerations listed in Section E.

Enter the county identifier or Civil Agreement number.

Enter the land class.

Enter acres being protected. If less than one acre, enter “1”.

Enter the name of the WS employee(s) conducting work on this project, or the WS employee to whom the responsibility of this project is assigned.

B. Species to be targeted - Mark the appropriate box(es) to indicate the species that will be targeted in the damage management actions. If “OTHER” is marked, list by species common name.

C. Components to be used - Mark the appropriate box(es) to indicate components to be used in the project. If Alpha Chloralose is to be used, mark the box and enter the INAD Number for the formulation to be used. If DRC-1339 is listed, or another chemical, enter the EXACT formulation to be used by recording the EPA or State registration number. If “OTHER” is marked, list by name and provide EPA or FDA registration number for any chemicals listed.

D. Have the Cooperator read, or read for the Cooperator, the information in this Section.

E. Special Considerations: Any special considerations agreed upon between the Cooperator and WS must be entered in this Section.

F. Enter the name of the landowner, lessee, or administrator of the property where this project will occur. Enter the address and phone number of the entity named in the appropriate box to the right.

G. Have the entity identified in G. as the landowner, lessee, or administrator sign on this signature line and place a date in the “date” block to the right.

H. The APHIS (WS) representative signs and enters title, duty station or office address, phone number, and date in this Section. Provide copies to the Cooperator, and as directed by the WS State Director.