WS Form 12B Work Initiation Document for Wildlife Damage Management

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 .038 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 wildlife damage management (Multiple Resource Owners)

1.

2.

/ /

Work Initiation Document Number

MM

DD

YYYY

Section 1

3. Type of Work initiation Document (mark all that apply):

Private Property

Temporary

Continuation Form

Amendment to Existing Work Initiation Document

Non-Private Property

Urban

Addendum on File

Special Considerations (see Section 6 below)

Section 2

4. WS Employee and Work Location Information:

5. Land Class Information:

6. Adjoining Property Work Initiation Document Number(s):

7. Species Information:

Land Class

Acres

1.

1.

1.

WS Employee Name

2.

2.

2.

3.

3.

3.

Other WS Employee

4.

4.

4.

County

Total Acres

5.

State

Addendum attached for other species.

Section 3

8a. Common Name of Property Allotment _________________________________________________________ b. ________________________________________ Allotment Number

Section 4

9. Components allowable on this project: Components: a. ______________________________ b. ___________________________________ c. _______________________________ d. ____________________________________________ e. ___________________________________ f. _______________________________ If box is marked, an attachment lists additional methods or devices.

Section 5

10. a.

Resource Owner’s Name:

Telephone Number (including Area Code):

Resource Owner’s Address (including ZIP Code):

b.

Resource Owner’s Name:

Telephone Number (including Area Code):

Resource Owner’s Address (including ZIP Code):

c.

Resource Owner’s Name:

Telephone Number (including Area Code):

Resource Owner’s Address (including ZIP Code):

d.

Resource Owner’s Name:

Telephone Number (including Area Code):

Resource Owner’s Address (including ZIP Code):

Section 6

Special Considerations:

WS FORM 12B

MAR 2010

Instructions for Completing WS Form 12 B

Work Initiation Document for Wildlife Damage Management

(Multiple Resource Owners)

This form is used to obtain information about an agreement in which multiple resource owners are involved.

SECTION 1 – Document Initiation Information

1. Enter the Work Initiation Document number assigned.

2. Enter the current month, day, and year as MM/DD/YYYY.

3. Identify the type(s) of agreements that apply to the control of wildlife damage on non-private property. Mark all boxes that apply.

SECTION 2 – WS Employee, Property, and Species Information

4. Enter the name of the primary WS employee working on this project, the name of any additional employee(s) assisting, the county name, and State where the project is worked.

5. Enter land class names for each land class and acreages associated with this Work Initiation Document. Add acreages for “Total Acres.”

6. If this Work Initiation Document includes doing work on adjoining or adjacent properties to address the damage problem on the primary property, list each Work Initiation Document number for each additional property in this subsection.

7. Enter species names for all species to be addressed on this project. If additional species need to be listed, attach a WS Form 12B Addendum and mark the box at the bottom left of this block.

SECTION 3 – Property Name and Allotment Number

8. a. Enter the common name of the property allotment if this is an allotment project.

b. Enter the allotment number if this is an allotment project.

SECTION 4 – Components Allowed

9. List all components to be used.

SECTION 5 – Resource Owner Information

10. a. – d. List all resource owners for which this agreement applies with addresses and telephone numbers for each.

SECTION 6 – Special considerations and cooperator information

11. Record any special considerations agreed upon for this project. Distribute copies in accordance with instructions from your supervisor. The Privacy Act Notice required to be given to the cooperator is on the back of the Cooperator Copy of this form.

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, and 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 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/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.