Form 3-202-15 Eagle Take Annual Report

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

EAGLE TAKE (50 CFR 22.26) - ANNUAL REPORT
PERMITTEE: _____
ADDRESS: _

_____________________________________

PERMIT NUMBER:_______________________________

___________________________________________

REPORT FOR CALENDAR YEAR*: ________________
*Programmatic take only
REPORT DUE DATE: _____________________________

_______________________________________________________
City

State

Zip Code

 Check here if reporting a change of name, address, or contact information

PHONE: ___________________________ Email: ______________________________

INSTRUCTIONS: Use section A (pp 1-2) to report eagle observations when monitoring for possible disturbance. Use section B (pp 3-4) to report eagle injuries and
mortality. Type or print the information requested below for each Important Eagle-Use Area (IEUA) identified on your permit during the year covered by this report and return the
completed report to the above address by the due date. Use of this form is not mandatory, but the same information must be submitted, including a signed certification statement. Filing an
annual report is a condition of your permit. Failure to file a timely and accurate report can result in permit suspension. Accurate reporting will play an essential role in future eagle
management.
Instructions for Section A: Continue data entry for each IEUA on additional Sec A Supplemental Sheet. (You may need to make or print copies of the blank supplemental sheet.)
Use a separate supplemental sheet for each IEUA identified on your permit.

A.

MAKE SUREAREA:
YOU SIGN & DATE THE CERTIFICATION STATEMENT BELOW BEFORE YOU SUBMIT YOUR REPORT.
IMPORTANT EAGLE-USE

(1) If your permit authorized disturbance at a nest, was the nest successful in this past year (i.e., were any juveniles eagles fledged)? Yes  No  Unknown 
(2) If more than one of one type of IEUA is identified on your permit, designate which nest (or roost or foraging area) data applies to.
DATE
TIME
NUMBER OF
OBSERVED BEHAVIOR
DESCRIPTION OF HUMAN ACTIVITY
P – perched
IF– in flight
EAGLES
OF DAY
EAGLES OBSERVED
AT TIME EAGLES WERE OBSERVED
F – feeding
N – sitting on or
(If in large numbers, please
(e.g., surveying; excavation; interior work, etc.)
OBSERVED
estimate)

AB – agitated behavior

attending nest

If activity is completed, enter “Completed”

CERTIFICATION: I certify that the information in this report 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/principal officer. (No photocopied or stamped signatures)
Form 3-202-15
(Rev 12/2013)

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

Expires xx/xx/2017

Section A Supplemental Sheet
EAGLE TAKE ANNUAL REPORT

REPORT YEAR__________

SUPPLEMENTAL PAGE #:____

PERMITTEE:__________________________________

PERMIT NUMBER:__________________

IMPORTANT USE AREA :
Identify nest, communal roost, or foraging area. Use a separate supplemental sheet for each IUA
DATE
EAGLES OBSERVED

Form 3-202-15

TIME
OF DAY

(Rev 12/2013)

NUMBER OF
EAGLES
OBSERVED
(If in large numbers, please
estimate)

OBSERVED BEHAVIOR
P – perched
F – feeding
N – sitting on or
attending nest

IF– in flight
AB – agitated
behavior

DESCRIPTION OF HUMAN ACTIVITY
AT TIME EAGLES WERE OBSERVED
(e.g., surveying; excavation; interior work, etc.)
If activity is completed, enter “Completed”

OMB Control No. 1018-0022

Expires xx/xx/2017

Section B - Report of eagle injuries and mortality.
INSTRUCTIONS: Instructions for Section B: Report eagle injuries and mortality. Use a separate supplemental sheet for each discreet geographic area covered by your
permit (e.g. “South tract” or “Clark County” or “Management Area xxxx.” Continue data entry for each geographic area on an additional Sec B Supplemental Sheet. (You
may need to copy or print more blank supplemental sheets.
MAKE SURE YOU SIGN & DATE THE CERTIFICATION STATEMENT BELOW BEFORE YOU SUBMIT YOUR REPORT

B.

GEOGRAPHIC AREA OF REPORTING:
Identify project/activity area
DATE
DISCOVERED

SPECIFIC
LOCATION
(e.g. utility pole #xx)

SPECIES
Bald or Golden

Was this data entered into a FWS electronic reporting system?  YES
 NO
If “yes” select the system:
 Avian Injury/Mortality Reporting System (AIMRS)
 Bird Injury/Mortality Reporting System (BIMRS)?
ADDITIONAL COMMENTS
STATUS OF EAGLE
DISPOSITION
Use this area to provide additional
Use:
Use:
“I” for injured,
“D” for dead, or
“C” for uninjured but caught or
trapped in equipment or
infrastructure

“NER” if sent to the National
Eagle Repository;
“PR” if transferred to permitted
eagle rehabilitator;
“R” if released;
“TA” if transferred to USFWS or
State agency;
Other (Please specify)

explanation, if needed, (e.g., name and
permit number of rehabilitator if you
entered “PER” under “DISPOSITION” ).

CERTIFICATION: I certify that the information in this report 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/principal officer. (No photocopied or stamped signatures)
Form 3-202-15 (Rev 12/2013)

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

Section B Supplemental Sheet
GEOGRAPHIC AREA OF REPORTING :
Identify project/activity area
DATE
DISCOVERED

Form 3-202-15

SPECIFIC
LOCATION
(e.g. utility pole #xx)

(Rev 12/2013)

SPECIES
Bald or Golden

Was this data entered into a FWS electronic reporting system?  YES
 NO If “yes”
select the system:
 Avian Injury/Mortality Reporting System (AIMRS)
 Bird Injury/Mortality Reporting System (BIMRS)?
ADDITIONAL COMMENTS
STATUS OF EAGLE
DISPOSITION
Use this area to provide additional
Use:
Use:
“I” for injured,
“D” for dead, or
“C” for uninjured but
caught or trapped in
equipment or infrastructure

“NER” if sent to the National
Eagle
Repository;
“PR” if transferred to permitted eagle
rehabilitator;
“R” if released;
“TA” if transferred to USFWS or State
agency;
Other (Please specify)

explanation, if needed, (e.g., name and
permit number of rehabilitator if you entered
“PER” under “DISPOSITION.”

OMB Control No. 1018-0022

Expires xx/xx/2017

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 type of permit held. The relevant burden for a Standard Eagle Take permit annual report is 30 hours
(including monitoring and recordkeeping). The relevant burden for a Programmatic Eagle Take permit annual report for an individual is 342 hours (including monitoring and
recordkeeping). 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

Region 1

Hawaii, Idaho, Oregon, Washington

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

Region 2

Arizona, New Mexico, Oklahoma, Texas

P.O. Box 709
Albuquerque, NM 87103

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]

Region 4

Alabama, Arkansas, Florida, Georgia, Kentucky,
Louisiana, Mississippi, North Carolina, South
Carolina, Tennessee, Virgin Islands, Puerto Rico

P.O. Box 49208
Atlanta, GA 30359

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

Region 5

Connecticut, District of Columbia, Delaware,
Maine, Maryland, Massachusetts, New Jersey,
New Hampshire, 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

Region 7

Alaska

Region 8

California, Nevada

P.O. Box 25486
DFC(60154)
Denver, CO 80225-0486
1011 E. Tudor Road
(MS-201)
Anchorage, AK 99503
2800 Cottage Way
Room W-2606
Sacramento, CA 95825

Tel. (303) 236-8171
Fax (303) 236-8017
Email [email protected]
Tel. (907) 786-3693
Fax (907) 786-3641
Email [email protected]
Tel. (916) 978-6183
Fax (916) 414-6486
[email protected]

CONTACT INFORMATION
Tel. (503) 872-2715
Fax (503) 231-2019
Email [email protected]
Tel. (505) 248-7882
Fax (505) 248-7885
Email [email protected]