Notification of Entanglement or Interaction

OMB Control No. 0648-XXXX

Expiration Date:

NOTIFICATION OF ENTANGLEMENT OR INTERACTION WITH MARINE MAMMALS, ENDANGERED SPECIES, OR MARINE MIGRATORY BIRDS

FOR OFFICE USE ONLY
Date Received
Gulf Aquaculture Permit Number
Reviewer Initials and Date

All events must be reported to NMFS within 24 hours of discovery by calling (XXX) XXX- XXXX.

Part 1 – Contact Person Information

LAST NAME FIRST NAME MIDDLE NAME Suffix (Sr., II, etc.) MAILING ADDRESS Apt/Suite #

CITY STATE COUNTY ZIP CODE

WORK TELEPHONE NUMBER CELL PHONE NUMBER GULF AQUACULTURE PERMIT NUMBER

_{Part 2 – Event Information}

: AM / PM

/ /

DATE OF EVENT (MM/DD/YYYY) TIME OF EVENT

Provide the GPS coordinates for the location where the event occurred. Report coordinates as

Degree Minutes to the third decimal place.

LATITUDE (DEGREE MINUTES TO THIRD DECIMAL PLACE) LONGITUDE (DEGREE MINUTES TO THIRD DECIMAL PLACE)

Was this an entanglement or interaction event?

Entanglement Interaction Both

_{List the species entangled or involved in interactions and number of individuals affected.}

1)	Genus and Species Number of Individuals
2)
3)
4)
5)

Describe the number and nature of mortalities and/or acute injuries observed.

Provide information on the cause(s) of the entanglement and/or interaction.

Provide information on the action(s) being taken to prevent future entanglements or interactions.

_{Part 3 – Signature}

I hereby declare under penalty of perjury that the foregoing information is true and correct (28

U.S.C. section 1746; 18 U.S.C. section 1621; 18 U.S.C. section 1001).

PERMIT OWNER SIGNATURE DATE SIGNED (MM/DD/YYYY)

_{/ /}

PRINTED NAME POSITION IN COMPANY (if applicable)

Public reporting burden for this collection of information is estimated to average 30 minutes 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. Send comments regarding this burden estimate or other suggestions for reducing this burden to PRA Officer, National Marine Fisheries Service. F/SER26, 263 13th Avenue South, St. Petersburg, FL 33701.

The National Marine Fisheries Service requires this information for the conservation and management of marine fishery resources. The data reported will be used to develop, implement, and monitor fishery management activities for a variety of other uses. Responses to this collection are required to obtain or retain a fisheries permit under the Magnuson-Stevens Act. Name and address information will be released via a NMFS website. All other data submitted will be handled as confidential material in accordance with NOAA Administrative Order

216-100, Protection of Confidential Fishery Statistics. Notwithstanding any other provisions of the law, no person is required to respond to, nor shall any person be subjected to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information

displays a currently valid OMB Control number.

2