WS 35 Report of Injury or Death to Non-target Animals

Clear Form
OMB Approved
0579-0335
EXP: XX/XXXX

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 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.

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

REPORT OF INJURY OR DEATH OF
NONTARGET ANIMAL

SECTION I - DESCRIPTION OF ANIMAL
1. SPECIES

2. BREED (if applicable)

3. ESTIMATED WEIGHT

4. AGE CLASS

5. SEX
Male

Female

SECTION II - DOMESTIC ANIMAL DISCOVERY INFORMATION
6. DID OWNER CONTACT WS?
YES

7. VALUE OF ANIMAL (if known)

8. WHO FOUND ANIMAL? (optional)

9. CONTACT INFORMATION (address, phone number) (optional)

NO

SECTION III - ANIMAL OWNER AND LAND OWNER INFORMATION
10. NAME OF ANIMAL OWNER

11. TELEPHONE NUMBER

12. STREET ADDRESS OR P.O. BOX

13. CITY

16. NAME OF PROPERTY OWNER OR LAND MANAGEMENT OFFICE

17. TELEPHONE NUMBER

18. STREET ADDRESS OR P.O. BOX

19. CITY

14. STATE

15. ZIP CODE

20. STATE

21. ZIP CODE

SECTION IV - ACCIDENT LOCATION AND LAND OPERATOR INFORMATION
22. ACCIDENT LOCATION (GPS coordinates, or nearest city or town, ranch or highway intersection, or Township-Range-Section if authorized)
a. GPS COORDINATES

b. TOWNSHIP-RANGE-SECTION

c. COUNTY OR PARISH

d. STATE

23. LAND CLASS
PRIVATE

BLM

USFS

STATE

24. NAME OF LAND OPERATOR (OR LESSEE) (if applicable)

25. TELEPHONE NUMBER

26. STREET ADDRESS OR P.O. BOX

27. CITY

OTHER

28. STATE

29. ZIP CODE

SECTION V - DEATH / INJURY INFORMATION
30. DISPOSITION OF ANIMAL
INJURY

34. WHO NECROPSIED OR SAMPLED?

35. FINDINGS

37. DID ANIMAL BELONG TO OWNER OR LESSEE
WHERE CONTROL WORK WAS BEING DONE?

38. WAS AGREEMENT CURRENT?

NO

36. WORK IN THE AREA?
YES

32. CAUSE (if injury, describe)

DEATH

33. WAS NECROPSY CONDUCTED OR
SAMPLE TESTED FOR TOXIC
MATERIALS?
YES

31. DATE OF INJURY OR DEATH

NO

YES

NO

YES

39. WAS CONTROL SITE PROPERLY POSTED
WITH READABLE SIGNS?

NO

YES

NO

SECTION VI - REPORT OF INCIDENT
(attach additional sheets as necessary as well as statements from witnesses, photocopy of agreement, map of location, and photos of site and animal if possible)
40. IN CASES INVOLVING THREATENED AND ENDANGERED (T&E) SPECIES, NOTE SIGNIFICANCE OF LOSS TO LOCAL OR NATIONAL POPULATION

41. WAS T&E SPECIES PREVIOUSLY KNOWN TO EXIST IN AREA?

YES

NO

SECTION VII - CHEMICAL
42. TYPE

43. STRENGTH

46. SYMPTOMS EVIDENT

44. REGISTRATION NUMBER

45. CARRIER BAIT

47. TIME ELAPSED INGESTION TO DEATH

48. ANIMAL’S PROXIMITY TO TOXICANT

SECTION VIII - MECHANICAL
49. TYPE

50. DESCRIBE SET

51. ESTIMATED TIME ANIMAL IN
EQUIPMENT

52. DATE OF LAST EQUIPMENT CHECK

SECTION IX - NATURE AND PURPOSE OF CONTROL WORK BEING CONDUCTED (i.e., depredation request, rodent control, etc.)

WS FORM 35
DEC 2016

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. 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
WS FORM 35, REPORT OF INJURY OR DEATH OF NONTARGET ANIMAL
This form is used to record the injury or death of a non-target animal at a WS project site when the incident
is known or highly suspected of being the result of some action or method used by WS personnel in a
wildlife damage management activity.
Section I - DESCRIPTION OF ANIMAL
1. Enter the name of the species that was injured or killed
2. Enter the breed of the animal, if applicable
3. Enter the approximate weight of the animal and include KG or LB (one KG = 2.5 LB)
4. Enter the age class of the animal as Immature or Adult
5. Enter the sex of the animal
Section II – DOMESTIC ANIMAL DISCOVERY INFORMATION
6. Mark appropriate box to indicate whether or not the owner contacted WS
7. Enter the monetary value of the animal, if known. Estimates may be used.
8. (Optional) Enter the name of the individual who found the animal
9. (Optional) Enter contact information for the individual who found the animal, if available
Section III – ANIMAL OWNER AND LAND OWNER INFORMATION
10. - 15. Enter the name, telephone number, and address of the animal’s owner, if known. If
unknown, enter Unknown for domestic animals and Wild for wild animals
16. - 21. Enter the name, telephone number, and address of the property owner or land management
office for the land where the animal was found
Section IV – ACCIDENT LOCATION AND LAND OPERATOR INFORMATION
22. Using the best available information, describe the location where the animal was found. If you
have GPS or Township/Range coordinates, enter them in the appropriate box.
23. Check the appropriate box to indicate the land class where the animal was found
24. - 29. Enter the name, telephone number, and address of the land operator or lessee if the land on
which the animal was found was property leased (and/or operated) by an individual/group different
than the property owner listed in Section 3. If the land operator is the same as the property owner,
enter 3A in the Block 4C.
Section V – DEATH / INJURY INFORMATION
30. Check the appropriate box to indicate whether the animal was found injured or dead
31. Enter the date of the injury or death. If unknown, enter the date the animal was found.
32. Describe briefly the cause of death or injury (e.g., for a death: M-44; for an injury: right front foot
injured by foothold trap)
33. Check the appropriate box to indicate whether a necropsy of the animal was performed or a
sample of toxic material was tested
34. Name of individual / institution performing the necropsy or sample test
35. Briefly describe the findings of the necropsy or test
36. Check the appropriate box to indicate whether the animal’s owner was aware of control work being
done in the area

INSTRUCTIONS FOR COMPLETING WS FORM 35 (Cont’d)

37. Check the appropriate box to indicate whether the animal belonged to the owner or the lessee of
the property where control work was being done
38. Check the appropriate box to indicate whether or not the agreement for this property was current
39. Check the appropriate box to indicate whether this control site was properly posted with readable
signs
Section VI – REPORT OF INCIDENT
40. If this event involved T&E species, briefly note the significance of the loss or injury of this animal to
local or national populations of the species
41. Check the appropriate box to indicate whether T&E species were previously known to exist in the
area. Check YES only if an official sighting of the T&E species that was involved in this incident
has been recorded for the site.
Section VII – CHEMICAL
42. Enter the type of chemical involved in this incident, if appropriate. If no chemical was involved in
this incident, enter N/A.
43. If a chemical was involved in this incident, enter the strength of the chemical
44. If a chemical was involved in this incident, enter the registration number of the chemical
45. If a chemical was involved in this incident, enter the carrier bait that was used for the chemical
46. Enter any symptoms that might relate to chemical effects which are evident when examining the
animal
47. If this incident involved ingestion of a substance/material by the affected animal, enter the time that
may have elapsed from ingestion to the onset of symptoms or death, if known
48. If this incident involved a toxin, enter the animals proximity to the toxin
Section VIII – MECHANICAL
49. Enter the type of mechanical device involved in this incident
50. Briefly describe the set
51. Enter the estimated (or known) time the animal was in the equipment
52. Enter the date of the last equipment check
Section IX – NATURE AND PURPOSE OF CONTROL WORK BEING CONDUCTED
Enter a brief description of the nature and purpose of control work being conducted in the area where
the animal was discovered

DISTRIBUTION OF THE COMPLETED WS FORM 35
Original - USDA Wildlife Services State Office
Copy

- USDA Wildlife Services District Office

Copy

- USDA Wildlife Services employee conducting control activities

Provide a copy of the Privacy Act Notice found on the reverse of the WS 35 to any non-government
contributor providing information for completing this form.