Form 3-202-4 Migratory Bird Rehabilitation - Annual Report

FWS Form 3-202-4 (Rev. 01/2020)
U.S. Department of the Interior

OMB Control No. 1018-0022
Expires ##/##/####
MIGRATORY BIRD REHABILITATION - ANNUAL REPORT
U.S. Fish and Wildlife Service
Division of Migratory Bird Management

BEFORE FILLING OUT THIS FORM, please access the Return Addresses (to
obtain the email/postal mail addresses where this form can be returned).

Report Year: ___________________________

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 (Please only use the following): R=Released; T=Transferred; P=Pending; E=Euthanized; D=Died; DoA=Dead on Arrival.
A. BIRDS HELD OVER. 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.
Common Name (Enter eagles first)

Date
Acquired

Disposition (check one)

Nature of Injury

R

T

E

D

Date of
Disposition

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)
Pending
Euthanized

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 of permittee/Principal Officer. (No stamped signatures/Electronic signatures accepted)
Continue to next page

_______________________________
Date of signature (mm/dd/yyyy)

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OMB Control No. 1018-0022
FWS Form 3-202-4 (Rev. 01/2020)
Expires ##/##/####
U.S. Department of the Interior
Pg.
REHABILITATION PERMIT ANNUAL REPORT - YEAR
PERMIT NO.
C. REPORTED INJURIES/MORTALITIES. Please complete for each individual bird received that was shot, poisoned (confirmed), electro-cuted,
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.
Date
Acquired

Common Name
(Enter eagles first)

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

Proposed Disposition
(check one)
R
T

Nature of Injury

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
(Enter eagles first)

Name

Name and Permit Number or Address

Date

Purpose
of Transfer

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.

Common Name
(Enter eagles first)

Date
Acquired

Name of Disease
or Contaminant

Concentration
of toxin, or if
infectious
disease, test
used for
diagnosis

Tissue Tested
(e.g., blood/
bone/ brain/
liver/kidney/ GI
tract contents)

Name of Lab
& State

Source of Bird
(County &
State)

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OMB Control No. 1018-0022
Expires ##/##/####

FWS Form 3-202-4 (Rev. 01/2020)
U.S. Department of the Interior
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.
Disposition (enter quantity)
Common Name
Total Number
(Enter eagles first)
Received
Released
Transferred
Pending
Died
DoA
Euthanized

SUBTOTAL OF EACH COLUMN
(Enter Grand Total on page 1)

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OMB Control No. 1018-0022
Expires ##/##/####

FWS Form 3-202-4 (Rev. 01/2020)
U.S. Department of the Interior
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..
Disposition (check one)
Common Name
Date
Cause/Nature
(A) Date of Disposition or
(Enter eagles first)
of Injury
Acquired
Source: County&State
R
T
P
E
D
DoA

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).
Common Name (Enter
eagles first)

Transferred to (Recipient)
Name

Name and Permit Number or Address

Date

Purpose
of
Transfer

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FWS Form 3-202-4 (Rev. 01/2020)
U.S. Department of the Interior

OMB Control No. 1018-0022
Expires ##/##/####

NOTICES
PRIVACY ACT STATEMENT
Authority: The information requested is authorized by the following: the Bald and Golden Eagle Protection Act (16 U.S.C. 668), 50 CFR
22; the Endangered Species Act (16 U.S.C. 1531-1544), 50 CFR 17; the Migratory Bird Treaty Act (16 U.S.C. 703-712), 50 CFR 21; the
Wild Bird Conservation Act (16 U.S.C. 4901-4916), 50 CFR 15; the Lacey Act: Injurious Wildlife (18 U.S.C. 42), 50 CFR 16; Convention
on International Trade in Endangered Species of Wild Fauna and Flora (TIAS 8249), 50 CFR 23; General Provisions, 50 CFR 10; General
Permit Procedures, 50 CFR 13; and Wildlife Provisions (Import/export/transport), 50 CFR 14.
Purpose: The collection of contact information is to verify the individual has an eligible permit to conduct activities which affect protected
species. The information the individual provides helps the FWS monitor and report on protected species and assesses the impact of
permitted activities on the conservation and management of species and their habitats.
Routine Uses: The collected information may be used to verify an applicant’s eligibility for a permit to conduct activities with protected
wildlife; to provide the public and the permittees with permit related information; to monitor activities under a permit; to analyze data and
produce reports to monitor the use of protected wildlife; to assess the impact of permitted activities on the conservation and management
of protected species and their habitats; and to evaluate the effectiveness of the permit programs. More information about routine uses
can be found in the System of Records Notice, Permits System, FWS-21.
Disclosure: The information requested in this form is voluntary. However, submission of requested information is required to
process applications for permits authorized under the listed authorities. Failure to provide the requested information may be sufficient
cause for the U.S. Fish & Wildlife Service to deny the request.
PAPERWORK REDUCTION ACT STATEMENT
In accordance with the Paperwork Reduction Act (44 U.S.C. 3501), the U.S. Fish and Wildlife Service collects information necessary to
monitor take and disposition of migratory birds, under the applicable laws governing the requested activity, for which a permit is
requested, and to respond to requests made under the Freedom of Information Act and the Privacy Act of 1974. Information requested in
this form is purely voluntary. However, submission of requested information is required in order to process applications for permits
authorized under the above laws. Failure to provide all requested information may be sufficient cause for the U.S. Fish and Wildlife
Service to deny the request. 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 currently valid OMB control number. OMB has approved this
collection of information and assigned Control No. 1018-0022.
ESTIMATED BURDEN STATEMENT
We estimate public reporting for this collection of information averages:
Original submission - paper-based: 2 hours 30 minutes (reporting) and 30 minutes (recordkeeping)
Original submission - electronic: 2 hours (reporting) and 30 minutes (recordkeeping)
These estimates include time for reviewing instructions, gathering and maintaining data and completing and reviewing the form. Direct
comments regarding the burden estimate or any other aspect of the form to the Service Information Clearance Officer, Fish and Wildlife
Service, U.S. Department of the Interior, 5275 Leesburg Pike, MS: PRB (JAO/3W), Falls Church, VA 22041-3803, or via email at
[email protected]. Please do not send your completed form to this address.
FREEDOM OF INFORMATION ACT
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 nonconfidential summary and remaining documents may be made available to the public under FOIA [43 CFR 2.26 – 2.33].

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