WS 12B Work Initiation Document for Wildlife Damage Management

Clear Form
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 5 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.

WORK INITIATION DOCUMENT FOR
WILDLIFE DAMAGE MANAGEMENT

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
WILDLIFE SERVICES

(Multiple Resource Owners)

SECTION 1

1. WORK INITIATION DOCUMENT NUMBER

2. DATE PREPARED (MM DD YYYY)

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

4. WS EMPLOYEE AND WORK
LOCATION INFORMATION

5. LAND CLASS INFORMATION

(see Item 15 below)

6. ADJOINING
PROPERTY WID NO.’S

7. TARGETED SPECIES

A.

A.

F.

A.

B.

B.

G.

B.

C.

C.

H.

C.

D.

D.

I.

D.

E.

E.

J.

A. WS EMPLOYEE NAME

SECTION 2

LAND CLASS

ACRES

B. OTHER WS EMPLOYEE
C. COUNTY

D. STATE

There are additional targeted species

SECTION 3

E. TOTAL ACRES

(complete and attach WS Form 12 Addendum)

8A. COMMON NAME OF PROPERTY ALLOTMENT

8B. ALLOTMENT NUMBER

SECTION 4

9. COMPONENTS ALLOWABLE ON THIS PROJECT
A.

B.

C.

D.

E.

F.

There are additional methods or devices (complete and attach WS Form 12 Addendum)
10.

SECTION 5

11.

12.

13.

14.

SECTION 6

OMB Approved
0579-0335
EXP: XX/XXXX

A. LANDOWNER, LESSEE, OR ADMINISTRATOR NAME AND TITLE

B. TELEPHONE NUMBER

C. ADDRESS (including ZIP code)

D. DATE SIGNED

A. LANDOWNER, LESSEE, OR ADMINISTRATOR NAME AND TITLE

B. TELEPHONE NUMBER

C. ADDRESS (including ZIP code)

D. DATE SIGNED

A. LANDOWNER, LESSEE, OR ADMINISTRATOR NAME AND TITLE

B. TELEPHONE NUMBER

C. ADDRESS (including ZIP code)

D. DATE SIGNED

A. LANDOWNER, LESSEE, OR ADMINISTRATOR NAME AND TITLE

B. TELEPHONE NUMBER

C. ADDRESS (including ZIP code)

D. DATE SIGNED

A. WILDLIFE SERVICES REPRESENTATIVE NAME AND TITLE

B. TELEPHONE NUMBER

C. ADDRESS (including ZIP code)

D. DATE SIGNED

15. SPECIAL CONSIDERATIONS

WS FORM 12B
OCT 2017

E. SIGNATURE

E. SIGNATURE

E. SIGNATURE

E. SIGNATURE

E. SIGNATURE

PRIVACY ACT NOTICE
5 U.S.C. 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
7 U.S.C. Sections 8351 to 8353, and 16 U.S.C. 667, authorizes officers, agents, and employees of the United States Department of Agriculture (USDA),
Animal and Plant Health Inspection Service (APHIS), Wildlife Services (WS) 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, 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
(1) To cooperative Federal, State, Tribal, and local government officials, employees, or contractors and other parties 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;
(2) To the appropriate agency, whether Federal, State, local, Tribal, 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;
(3) 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;
(4) 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;
(5) 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 of 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;
(6) To USDA contractors, partner agency employee or contractors, or private industry employed to identify patterns, trends, or anomalies indicative of
fraud, waste, or abuse;
(7) To land management agencies, such as the Bureau of Land Management and the U.S. Fish and Wildlife Service, relating to wildlife damage on
grazing allotments;
(8) To consumer reporting agencies in accordance with 31 U.S.C. 3711(e);
(9) To Federal, State, Tribal, and local regulatory agencies and their employees and contractors who collaborate with Wildlife Services in implementation
of, or agencies that regulate, wildlife management projects or programs, or who have an interest in, or regulate, animal or public health, or national
security;
(10) To Federal or State Government-level representatives of the U.S. Environmental Protection Agency, in compliance with the Federal Insecticide,
Fungicide, and Rodenticide Act (FIFRA) mandate in 7 U.S.C. 136(f, and i thru l), of the location on a cooperator’s property where certain regulated
pesticide devices are deployed or regulated pesticides are applied; and
(11) To the National Archives and Records Administration (NARA) 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.

Instructions for Completing WS Form 12B,
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 (WID) number assigned.

2.

Enter the current month, day, and year for which the WID is prepared.

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 the land class names for each land class and acreages associated with this WID. Enter the sum of all acreages in Item 5E.

6. If this WID includes doing work on adjoining or adjacent properties to address the damage problem on the primary property, list the WID
numbers for the additional properties.
7. Enter species names for all species to be addressed on this project. If more than 10 species are targeted, mark the addendum box and
list the additional species on WS Form 12 Addendum. Attach the addendum to the WS Form 12B.
SECTION 3 – Property Name and Allotment Number
8.

Enter the common name and allotment number of the property allotment if this is an allotment project.

SECTION 4 – Components Allowed
9. List all components to be used. If more than six components are used, mark the addendum box and list the additional methods or
devices on WS Form 12 Addendum. Attach the addendum to the WS Form 12B.
SECTION 5 – Landowner, Lessee, or Administrator, and Wildlife Services Representative Information
10-14. Annotate the names, titles, addresses, telephone numbers, and signatures of all resource owners for which this agreement applies,
and the same information for the Wildlife Services Representative.
SECTION 6 – Special Considerations and Cooperator Information
15. Record any special considerations agreed upon for this project. Distribute copies in accordance with instructions from your supervisor.
The WS employee is responsible for ensuring the Cooperator or authorized representative receives a copy of the WS Privacy Act Notice.