3-2542 Harvest Report - National Wildlife Refuge System Nationa

FWS Form 3-2542 (Rev. 04/2022) OMB Control. No. 1018-0140

U.S. Fish and Wildlife Service Expires ##/##/20##

H UNTER HARVEST REPORT

National Wildlife Refuge System

[NAME OF REFUGE/HATCHERY]

[Insert address, phone number, email,

Website, and/or other pertinent info]

(Refuge Use Only) [Refuges can customize this section to meet their specific permit harvest reporting requirements]

[Refuges/hatcheries will choose fields from lists below to create refuge/hatchery-specific custom harvest reporting forms. Unnecessary fields listed below may be removed. However, new fields may not be added. Questions on form usage/customization should be directed to the Service’s Information Collection Clearance Officer ([email protected]).]

HUNTER CONTACT INFORMATION: [Refuges/hatcheries will collect either hunter PII or State-issued ID#, but not both.]

Full Legal Name      

Mailing Address      

City      

State      

Zip Code      

OR

State Issued Hunter Identification/License Number

Area Code/Phone No.

Cell Home Other

Email Address      

COMPLETED HUNT INFORMATION:

Date of Report:      

Date(s) of Hunt(s):      

Permit Number/Type:      

Hunt Tag Number:      

Season Issued:      

Harvest Location/Unit/Area/Zone (Closest hunt lot or GPS coordinates) [Refuge/hatchery to insert appropriate description options]

Method (Check all that apply) [Refuge/hatchery to customize allowable method options]

Rifle Shotgun Archery Falconry Muzzleloader

Species Permit Type (Check all that apply) [Refuge/hatchery to customize allowable species options]

Deer Turkey Feral Hog Migratory Bird Waterfowl Raccoon Opossum

Youth Turkey Youth Hunt Other (Describe)      

Total Hours Hunted:      

Start Time am pm

End Time am pm

Number in Party (Please check one) 1 2 3 4 5 Other:      

Number of Youth (Under 18) in Party (Please check one) 1 2 3 4 5 Other:      

Harvest Data:

Harvest Type:

Big Game

Migratory Bird

Upland Small Game/Furbearer

Species:       [Refuge/hatchery to include list specific species available for harvesting]

Number harvested:       [May enter “0”, if appropriate, as well]

Number knocked down but not retrieved:      

Sex [e.g., options include male/female/buck/spike/cow/doe/calf/fawn, etc.] [Refuge/hatchery to insert responses options here]

Weight:      

Condition:       [Refuge/hatchery to insert specific condition responses here]

Harvested by: Adult or Youth [Refuge/hatchery to only use those two options, not specific names of hunters]

Size:       [Refuge/hatchery to insert specific dates/size requirements]

Species Observed:       [Refuge/hatchery list specific species]

Additional Comments:

     

NOTICES

All information you provide will be considered in reviewing this application. False, fictitious, or fraudulent statements or representations made in the application may be grounds for revocation of the permit and may be punishable by fine or imprisonment (18 U.S.C. 1001).

Privacy Act Statement

Authority:  The information requested is authorized by the National Wildlife Refuge System Administration Act (16 U.S.C. 668dd-ee) as amended and the Refuge Recreation Act (16 U.S.C. 460k – 460k-4, 640K-3, & 664).

Purpose:  The collection of personal information is to verify that an individual is eligible to receive a permit to conduct monitored activity on areas within the National Wildlife Refuge System, national fish hatcheries, and other conservation areas administered by the Secretary of the Interior for fish and wildlife purposes.  

Routine Uses:  The individual’s information will be used to verify permit status, provide permittees with permit-related information, and monitor activities conducted under a permit. This information may be shared in accordance with the Privacy Act of 1974 and the routine uses listed in the System of Records Notices: FWS-5 National Wildlife Refuge Special Use Permits; FWS-21 Permits System; FWS-10 National Fish Hatchery Special Use Permits.  

Disclosure:  Providing the information is voluntary; however, as a requirement for maintaining a Federal permit under the National Wildlife Refuge System Administration Act, failure to disclose the requested information may be sufficient cause for revocation of the permit.

Paperwork Reduction Act Statement

We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501 et seq.) to provide the refuge managers the information needed to decide whether or not to allow the requested use, and to respond to requests made under the Freedom of Information Act and the Privacy Act of 1974. The information that you provide is voluntary; however, submission of the requested information is required to evaluate the qualifications, determine eligibility, and document permit applicants. Failure to provide all required information is sufficient cause for the U.S. Fish and Wildlife Service to deny a permit. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a currently valid OMB control number. OMB has approved this collection of information and assigned OMB Control No. 1018-0140.

Estimated Burden Statement

Public reporting for this collection of information is estimated to average 15 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 any other aspect of this collection of information, including suggestions for reducing this burden, to the Service Information Clearance Officer, U.S. Fish and Wildlife Service, 5275 Leesburg Pike, MS: PRB (JAO/3W), Falls Church, VA 22041-3803, or via email at [email protected]. Please do not send your completed application to this address.

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