Form 3-202-4 Rehabilitation Annual Report

0

U.S. FISH & WILDLIFE SERVICE - MIGRATORY BIRD PERMIT OFFICE
Return to: U.S. Fish and Wildlife Service (USFWS)
or

REHABILITATION ANNUAL REPORT - REPORT YEAR ___________
Report Due: ___________
PERMITTEE:

PERMIT NUMBER:_____________________________________

ADDRESS:

PHONE NUMBER: ______________________________________

E-Mail: _____________________________________________________
City
State
Zip Code
 Check here if reporting a change of name, address, or contact information

INSTRUCTIONS: Please type or print the information requested below for all migratory birds held under your permit during the report year,
and return the completed report to the above address by January 31 of the following year. Use of this form is not mandatory, but the same
information must be submitted, including the signed certification statement. A supplemental sheet is available if needed. Do not include species
other than migratory birds in your report. Filing an annual report is a condition of your permit. Failure to file a timely report could result in
suspension of your permit. You must submit a report even if you had no activity during the year. Make sure you sign the certification at the
end of the form. (Ref. 50 CFR parts 13 & 21)
DISPOSITION CODES: R=Released; T=Transferred; P=Pending; E=Euthanized; D=Died; DoA=Dead on Arrival.
A. BIRDS HELD OVER 180 DAYS OR LONGER. Please list each individual bird that was held over from any previous report year for
continued care, and provide the following information. For DISPOSITION, check appropriate column. Also complete section E for all Transfers.
Disposition (check one)
Date
Date of
Common Name (Enter eagles first)
Acquired
Nature of Injury
Disposition
R
T
E
D

B. NEW ACQUISITIONS. Please provide a summary of all birds acquired during the report year, categorized and subtotaled by species. The
quantity in the Received column should equal the sum of the quantities in the Disposition column. Also complete sections D and E for Pending

and Transferred birds, respectively. All birds, including birds reported in C, D, E, and F must be reported here.
Common Name (Enter eagles first)

Total Number
Received

Released

Transferred

Disposition (enter quantity)
Euthanized
Pending

Died

DoA

GRAND TOTAL OF EACH COLUMN
(including for all supplemental sheets)
CERTIFICATION: I certify that the above information is true and correct to the best of my knowledge. I understand that any false
statement herein may subject me to the criminal penalties of 18 U.S.C. 1001.
__________________________________________________________________________
Signature (in blue ink) of permittee/principalofficer (No photocopied or stamped signatures)
Form 3-202-4 Rev 12/2013

Continue to next page

_______________________________
Date of signature (mm/dd/yyyy)
OMB Control No. 1018-0022

Expires x/xxxxxx

REHABILITATION PERMIT ANNUAL REPORT - YEAR

PERMIT NO.

(Pg. 2)

C. REPORTED INJURIES/MORTALITIES. Please complete for each individual bird received that was shot, poisoned (confirmed), electrocuted, trapped (e.g., foot-hold), or otherwise injured or killed as the result of a potentially criminal activity. (Such incidents should have been
reported immediately.) DISPOSITION CODES: R=Released; T=Transferred; P=Pending; E=Euthanized; D=Died; DOA=Dead on Arrival.
Common Name
(Enter eagles first)

Date
Acquired

Cause/Nature
of Injury

Disposition (check one)
R

T

P

E

D

DoA

Source
(County & State)

D. STILL PENDING. Please complete for each individual bird still held as of 12/31 of the report year. Please identify any birds you maintain
as foster parents with a circled “F” next to their common name. DISPOSITION CODES: R=Released; T=Transferred
Common Name
(Enter eagles first)

Date Acquired

Nature of Injury

Proposed Disposition
(check one)
R
T

E. TRANSFERS. Please complete for each individual LIVE bird you transferred during the report year (1/1-12/31). For Name and Permit
Number or Address, provide the permit number if applicable; if not applicable, provide name and address. For Purpose of Transfer, use the
following codes: R = Release; C = Continued Care; Live-E/S = Live- Education or Scientific Research Permit; F/P=Falconry or Raptor
Propagation permit; O=Other (please enter permit type).
Transferred to (Recipient)
Common Name
Purpose
(Enter eagles first)
of Transfer
Name
Name and Permit Number or Address
Date

F. OPTIONAL. - DISEASE & CONTAMINANTS. Providing the information requested below is voluntary. Please complete for any
individual birds received that were tested & were confirmed to have died of infectious disease such as West Nile virus (not parasites), or ingested
contaminants such as sodium pentobarbital, carbofuran, or lead. Note: The FWS does not require testing of birds for disease or contaminants
and the following information request should not be construed as a recommendation to do so. However, for any birds that you chose to have
clinically tested that resulted in a confirmed diagnosis, please provide the requested information. Do not include data on birds you suspect
succumbed as a result of disease or toxins but were not tested, or birds that were tested but results were inconclusive. Thank you.
Concentration
Tissue Tested
Date
of toxin, or if
Source of Bird
Name of Disease or
(e.g., blood/
Common Name
Acquirinfectious
Name of Lab
(County &
bone/ brain/
Contaminant
(Enter eagles first)
ed
disease, test
& State
liver/kidney/ GI
State)
used for
tract contents)
diagnosis

Form 3-202-4

Rev 12/2013

OMB Control No. 1018-0022

Expires x/xxxxxx

SUPPLEMENTAL SHEET - REHABILITATION ANNUAL REPORT - Year________ PERMIT NO.
__
Page ___
B. NEW ACQUISITIONS. Please provide a summary of all migratory birds acquired during the report year, categorized and subtotaled by
species. The quantity in the Received column should equal the sum quantities in the Disposition columns. Also complete sections D and E for

Pending and Transferred birds, respectively. All birds, including birds reported in C, D, E, and F must be reported here.
Common Name
(Enter eagles first)

Total Number
Received

Disposition (enter quantity)
Released

Transferred

Pending

Euthanized

Died

SUBTOTAL OF EACH COLUMN
(Enter Grand Total on page 1)
Form 3-202-4 Rev 12/2013

OMB Control No. 1018-0022

Expires x/xxxxxx

DoA

SUPPLEMENTAL SHEET - REHABILITATION ANNUAL REPORT - Year_________ PERMIT NO.
___
Page ____
A, C, or D. Use as additional space for completing sections A, C, or D. Indicate in the left column the letter of the section that corresponds to the
information you provide. DISPOSITION CODES: R=Released; T=Transferred; P=Pending; E=Euthanized; D=Died; DoA=Dead on Arrival..
Common Name
(Enter eagles first)

Date
Acquired

Cause/Nature
of Injury

Disposition (check one)
R

T

P

E

D

DoA

(A) Date of Disposition or
(B) Source: County&State

E. TRANSFERS. Please complete for each individual LIVE bird you transferred during the report year (1/1 - 12/31). For Name and Permit
Number or Address, provide the permit number if applicable; if not applicable, provide the name and address. For Purpose of Transfer, use the
following codes: R = Release; C = Continued Care; Live-E/S = Live- Education or Scientific Research Permit; F/P=Falconry or Raptor
Propagation permit; O=Other (please enter permit type).
Transferred to (Recipient)
Purpose
Common Name (Enter
of
eagles first)
Name
Name and Permit Number or Address
Date
Transfer

Form 3-202-4 Rev 12/2013

OMB Control No. 1018-0022

Expires x/xxxxxx

FEDERAL FISH AND WILDLIFE PERMIT REPORT
Paperwork Reduction Act, Privacy Act, and Freedom of Information Act – Notices
In accordance with the Paperwork Reduction Act of 1995 (44 U.S.C. 3501, et seq.) and the Privacy Act of 1974 (5 U.S.C. 552a), please be advised:
1.

The gathering of information on fish and wildlife is authorized by:
(Authorizing statutes can be found at: http://www.gpoaccess.gov/cfr/index.html and http://www.fws.gov/permits/ltr/ltr.html.)
a.
b.
c.
d.
e.

Bald and Golden Eagle Protection Act (16 U.S.C. 668), 50 CFR 22;
Migratory Bird Treaty Act (16 U.S.C. 703-712), 50 CFR 21;
General Provisions, 50 CFR 10;
General Permit Procedures, 50 CFR 13; and
Wildlife Provisions (Import/export/transport), 50 CFR 14.

2.

Information requested in this form is purely voluntary. However, submission of requested information is a condition of your permit under the above
laws. Failure to provide all requested information may be sufficient cause for the U.S. Fish and Wildlife Service to revoke your permit. Response is
not required unless a currently valid Office of Management and Budget (OMB) control number is displayed on form.

3.

Disclosures outside the Department of the Interior may be made without the consent of an individual under the routine uses listed below, if the disclosure is
compatible with the purposes for which the record was collected. (Ref. 68 FR 52611, September 4, 2003)
a.
b.
c.

d.
e.

f.
g.
h.

Routine disclosure to subject matter experts, and Federal, Tribal, State, local, and foreign agencies, for the purpose of obtaining advice relevant to
making a decision on an application for a permit or when necessary to accomplish an FWS function related to this system of records.
Routine disclosure to Federal, Tribal, State, local, or foreign wildlife and plant agencies for the exchange of information on permits granted or denied
to assure compliance with all applicable permitting requirements.
Routine disclosure to Federal, Tribal, State, and local authorities who need to know who is permitted to receive and rehabilitate sick, orphaned, and
injured birds under the Migratory Bird Treaty Act and the Bald and Golden Eagle Protection Act; federally permitted rehabilitators; individuals
seeking a permitted rehabilitator with whom to place a bird in need of care; and licensed veterinarians who receive, treat, or diagnose sick, orphaned,
and injured birds.
Routine disclosure to the Department of Justice, or a court, adjudicative, or other administrative body or to a party in litigation before a court or
adjudicative or administrative body, under certain circumstances.
Routine disclosure to the appropriate Federal, Tribal, State, local, or foreign governmental agency responsible for investigating, prosecuting,
enforcing, or implementing statutes, rules, or licenses, when we become aware of a violation or potential violation of such statutes, rules, or licenses,
or when we need to monitor activities associated with a permit or regulated use.
Routine disclosure to a congressional office in response to an inquiry to the office by the individual to whom the record pertains.
Routine disclosure to the Government Accountability Office or Congress when the information is required for the evaluation of the permit programs.
Routine disclosure to provide addresses obtained from the Internal Revenue Service to debt collection agencies for purposes of locating a debtor
to collect or compromise a Federal claim against the debtor or to consumer reporting agencies to prepare a commercial credit report for use by
the FWS.

4. For individuals, personal information such as home address and telephone number, financial data, and personal identifiers (social security number,
birth date, etc.) will be removed prior to any release of the application.
5. The public reporting burden for information collection varies depending on the activity for which a permit is requested. The relevant burden for a
Rehabilitation permit annual report is 3 hours. This burden estimate includes time for reviewing instructions, gathering and maintaining data and
completing and reviewing the form. You may direct comments regarding the burden estimate or any other aspect of the form to the Service
Information Clearance Officer, U.S. Fish and Wildlife Service, Mail Stop 222, Arlington Square, U.S. Department of the Interior, 1849 C Street, NW,
Washington D.C. 20240.
Freedom of Information Act – Notice
For organizations, businesses, or individuals operating as a business (i.e., permittees not covered by the Privacy Act), we request that you identify any
information that should be considered privileged and confidential business information to allow the Service to meet its responsibilities under FOIA.
Confidential business information must be clearly marked "Business Confidential" at the top of the letter or page and each succeeding page and must be
accompanied by a non-confidential summary of the confidential information. The non-confidential summary and remaining documents may be made
available to the public under FOIA [43 CFR 2.26 – 2.33].

Migratory Bird Regional Permit
Offices
FWS
REGION

AREA OF
RESPONSIBILITY

MAILING
ADDRESS

CONTACT
INFORMATION

Region 1

Hawaii, Idaho, Oregon,
Washington

911 N.E. 11th Avenue
Portland, OR 97232-4181

Tel. (503) 872-2715
Fax (503) 231-2019
Email [email protected]

Region 2

Arizona, New Mexico,
Oklahoma, Texas

P.O. Box 709
Albuquerque, NM 87103

Tel. (505) 248-7882
Fax (505) 248-7885
Email [email protected]

Region 3

Iowa, Illinois, Indiana,
Minnesota, Missouri,
Michigan, Ohio, Wisconsin

5600 American Blvd. West
Suite 990
Bloomington, MN
55437-1458
(Effective 5/31/2011)

Tel. (612) 713-5436
Fax (612) 713-5393
Email [email protected]

P.O. Box 49208
Atlanta, GA 30359

Tel. (404) 679-7070
Fax (404) 679-4180
Email [email protected]

Region 4

Region 5

Alabama, Arkansas, Florida,
Georgia, Kentucky, Louisiana,
Mississippi, North Carolina,
South Carolina, Tennessee,
Virgin Islands, Puerto Rico
Connecticut, District of
Columbia, Delaware, Maine,
Maryland, Massachusetts,
New Hampshire, New Jersey,
New York, Pennsylvania,
Rhode Island, Virginia,
Vermont, West Virginia

P.O. Box 779
Hadley, MA 01035-0779

Tel. (413) 253-8643
Fax (413) 253-8424
Email [email protected]

Region 6

Colorado, Kansas, Montana,
North Dakota, Nebraska,
South Dakota, Utah, Wyoming

P.O. Box 25486
DFC(60154)
Denver, CO 80225-0486

Tel. (303) 236-8171
Fax (303) 236-8017
Email [email protected]

Region 7

Alaska

1011 E. Tudor Road
(MS-201)
Anchorage, AK 99503

Tel. (907) 786-3693
Fax (907) 786-3641
Email [email protected]

Region 8

California, Nevada

2800 Cottage Way
Room W-2606
Sacramento, CA 95825

Tel. (916) 978-6183
Fax (916) 414-6486
[email protected]