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pdfOMB Control No. 0579-XXXX
SECTION 1
1.
__________________
Work Initiation
Document #
2 . _____/____/_____
UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
WILDLIFE SERVICES
WORK INITIATION DOCUMENT FOR WILDLIFE DAMAGE MANAGEMENT
M M
DD
YY
3. TYPE OF WORK INITIATION DOCUMENT (mark all that apply):
9
9
9
9
Private Property
Adjacent Landowner
4. Cooperator’s Name
Temporary
Addendum to a Work Initiation Doc.
Assign to These Special Groups:
a.
__________________________
Amendment to Existing
Work Initiation Doc.
b.
__________________________
c.
__________________________
____________________________________________________________________________________________________________
Last
First
Middle
5. Cooperator’s Address ____________________________________________________________________________________________________________
SECTION 2
Street
City
Where Will Work Be Performed? (give address or directions, if different from address above)_______________________________________________________
_________________________________________________________________________________________________________________________________
6. Business / Farm / Ranch / or Common Name _____________________________________________________ 7. _________
________________
State
8. Owner’s or Representative’s Name ______________________________________________ 9.
(If different from Cooperator’s)
Zip Code
_________________________________________
Cooperator Telephone Number (include Area Code)
10. Owner’s or Representative’s Address
(if different from Cooperator’s) ______________________________________________________________________________________________
Street
11. WS Employee and Work
Location Information
SECTION 3
_______________
WS Employee Name
_______________
County
13. Adjoining Property
Information Document #
State
Zip Code
14. Species Information
1. ________________________________
1_______________________
2. ________________________________
2. ______________________
3. ________________________________
2. _____________ _____________
3. _____________ _____________
3. ______________________
______________________
State
SECTION 4
12. Land Class Information
Land Class
Acres
1______________ _____________
City
4. ________________________________
4. _____________ _____________.
Total Acres
________________
4. ______________________
If box is checked, attachment
lists additional species
16. In consideration of the benefits to be derived from the proper management of damage caused by those species listed in Section 3 Item 14 (and Item 15 if applicable), I the undersigned
cooperator or cooperator’s representative, do hereby give my consent, and concurrence, to the Animal and Plant Health Inspection Service (APHIS) (to include its officials, employees, and
agents) to use, upon lands owned, leased, or otherwise controlled by me, and identified by this Work Initiation Document, the following methods and devices:
COMPONENTS: 1. ____________________________ 2._____________________________________ 3._________________________________
4.__________________________________________
18. I, the cooperator or cooperator’s representative, have been informed of the methods and the manner in which the control materials and devices listed in Section 4
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 3, Item 14 (and Item 15 if applicable); guard against the
mishandling of control devices and materials; and exercise due caution and proper judgment in all wildlife damage management operations. I understand the APHIS,
WS will maintain restricted use pesticide application records on applications made under this Work Initiation Document, and that APHIS, WS will provide copies of
the records or record information promptly upon the property owner’s or cooperator’s request. I understand that APHIS may collect Global Positioning System
(GPS) coordinates at the project site as part of component or activity tracking or as wildlife disease monitoring or research data.
19. In consideration of these understandings and of the benefits to be derived, I, the cooperator or cooperator’s representative, agree to: take reasonable precautions
to prevent injury to livestock and other domestic animals; assume responsibility for injury to my property or to the property under my control, when said injury is not
the result of negligence on the part of APHIS; assist in maintaining such warning signs as APHIS may place for the purpose of notifying persons entering onto such
lands of the possible hazards associated with wildlife damage management measures in use thereon; and to give adequate warning of these possible hazards to
persons I authorize to enter onto such lands. Further, in recognition of the benefits to be derived from the use of specified methods and devices authorized by this
Work Initiation Document, I, the cooperator or cooperator’s representative, agree not to concurrently use or allow to be used upon lands covered by this Work
Initiation Document, any toxic material that might reasonably be expected to take a species listed above in Section 3, Item 14 (and Item 15 if applicable) unless such
use of said toxicant is agreed to by APHIS in writing.
SECTION 8
SECTION 7
SECTION 5
GIf box is marked, an attachment lists additional methods or devices
SECTION 6
17.
5._____________________________________6.________________________________.
20. SPECIAL CONSIDERATIONS:
21. SIGNATURE AND TITLE (Landowner, Lessee, or Administrator)
ADDRESS
DATE
22. SIGNATURE / TITLE (APHIS Representative)
ADDRESS
DATE
PHONE
WS FORM 12A (2007)
According to the Paperwork Reduction Act of 1995, no persons are 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-XXXX. The time required to complete this information collection is estimated to average .059 minutes/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.
Instructions for Completing WS Form12 A – Work Initiation Document for Wildlife Damage Management
Section 1: Basic Work Initiation Information
Item
1
Work Initiation Document # - Record the assigned number for this document
2
Date - Enter the date the form is filled out.
3
Type of Document - Record the type of Work Initiation Document by marking the appropriate
box(es). Hint: A Work Initiation Document may have more than one characteristic. Example: A Work
Initiation Document can be a Temporary and Urban Document. If special group(s) assigned enter
name of group(s) in lines provided.
Section 2: Items in this section capture data about the Cooperator
4
Enter name of cooperator as it appears on the cooperative service agreement, cooperative service field
agreement, Memorandum of Agreement or Understanding, or as it appears in cooperator’s business
references
5
Enter the cooperator’s address, and alternate address or location if the primary address is different from
the site where work will be done.
6
Enter the name of the cooperator’s business, farm or ranch, if applicable
7
Enter the state abbreviation and the zip code
8
Enter the name of the owner or cooperator’s representative if it is different from the cooperator name,
the area code and telephone number of the owner
9
Enter the Cooperator’s telephone number, including the area code
10
Enter the property owner’s address (or property owner’s representative’s work address if this is a nonprivate agreement), including the zip code even if it is the same as item 6.
Section 3: Information about the WS employee conducting activities, the property being worked on, and
the species being addressed is captured in this section.
11
Employee Name, County and State - In this subsection, record the name of the WS employee, and the
state and county for the site where the work in being performed.
12
Land Class - Record the land class being worked on, and enter the number of acres for that land class.
Record the total acres by summing all entries in the “Acres” column.
13
Adjoining property - If the Work Initiation Document allows you to work on adjoining property as
part of the project, you must have additional Work Initiation Documents signed by those adjoining land
owners / managers. The Work Initiation Document numbers for those properties go in this subsection.
14
Species/Codes - List the names of the species that will be targeted during the damage management
activities. Official MIS abbreviations for the names of the species may be used
15
Additional Species - If more species are targeted than can be entered in this block, mark this box and
attach the WS Form 12A Addendum listing them.
Section 4 – Component Use Information
16
Components - List the type of components that will be used in the wildlife damage management
activity.
17
If more components are to be used than can be entered in the available space, mark this box and attach
the WS Form 12A Addendum listing them.
Section 5 – Work Initiation Considerations – WS Responsibilities
18
Allow the cooperator to read this section, or alternately, read it to the cooperator before signatures are
affixed.
Section 6 – Work Initiation Considerations – Cooperator Responsibilities
19
Allow cooperator to read this section, or alternately, read it to the cooperator before signatures are
affixed.
Section 7 – Special Considerations
20
Special Considerations - If any special considerations are agreed to for this project, enter them in this
section.
Section 8 - Signatures / Dates
21
Obtain the signature and address of the landowner, lessee, administrator, or representative of the project
land(s). Enter a date when the document was signed.
22
The WS Employee filling out the form signs and enters official title, telephone number, address, and
date.
Provide a copy to the cooperator after signature; keep one copy for your files, provide copy to the State Office,
provide copies to other WS personnel/offices as appropriate. Provide the cooperator a copy of the WS Privacy
Statement with this document.
____________
Work Initiation
Document #
UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
WILDLIFE SERVICES
ADDENDUM TO A WORK INITIATION DOCUMENT
________/________/_______
M M
D D
Y Y
1. In the document # boxes provided above, enter the number of the Work Initiation Document for which
this addendum is completed.
2. Enter the date the addendum is completed in the date boxes above. Enter as MM-DD-YY.
3. Enter additional species that will be addressed and additional components to be used in the spaces
provided below.
4. Obtain signature of Cooperator with date signed
5. Provide copies for each copy of the Work Initiation Document
Additional Species
1. ________________________________
9. ________________________________
17._______________________________
2. ________________________________
10. _______________________________
18. _______________________________
3. ________________________________
11. _______________________________
19.________________________________
4. ________________________________
12.________________________________
20.________________________________
5. ________________________________
13. _______________________________
21.________________________________
6. ________________________________
14,________________________________
22.________________________________
7.________________________________
15.________________________________
2.3________________________________
8. ________________________________
16.________________________________
24. _______________________________
1. ________________________________
9. ________________________________
17._______________________________
2. ________________________________
10. _______________________________
18. _______________________________
3. ________________________________
11. _______________________________
19.________________________________
4. ________________________________
12.________________________________
20.________________________________
5. ________________________________
13. _______________________________
21.________________________________
6. ________________________________
14,________________________________
22.________________________________
7.________________________________
15.________________________________
2.3________________________________
8. ________________________________
16.________________________________
24. _______________________________
Additional Components to Be Used
Cooperator Signature ________________________________________ Date________________________
WS Form 12A - Addendum
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 (USC), Section 426-426c, and Title 16 USC, 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. Further, 5 USC 552a authorizes USDA,
APHIS, Wildlife Services to collect information about private individuals for its system of records pursuant to the conduct of program activities with
those private individuals.
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.
| File Type | application/pdf |
| File Title | C:\Ongoing Work\FORMS\e-copy forms\Form 12 series\form 12A wGPS_disclaimer Feb07.wpd |
| Author | rmyers |
| File Modified | 2007-10-16 |
| File Created | 2007-02-22 |