Form 3-202-15 Annual Report - Eagle Incidental Take (50 CFR 22.26)

FWS Form 3-202-15 (Rev. 04/2022)
U.S. Department of the Interior

U.S. FISH & WILDLIFE SERVICE - MIGRATORY BIRD PERMIT OFFICE
EAGLE INCIDENTAL TAKE (50 CFR 22.80) - ANNUAL REPORT
BEFORE FILLING OUT THIS FORM, please access the Return Addresses (to obtain the email/postal mail
addresses where this form can be returned).

OMB Control No. 1018-0167
Expires ##/##/20##

PERMITTEE: __________________________________________

PERMIT NUMBER:_______________________________

ADDRESS: ____________________________________________

REPORT FOR CALENDAR YEAR*: ________________

_______________________________________________________

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 of this form to report eagle observations when monitoring for possible disturbance. For permits authorizing eagle injury and
mortalities, reports must be generated through the Service’s online reporting system. Refer to section B for instructions on reporting eagle injuries and mortalities.
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.
A.

IMPORTANT EAGLE-USE AREA: 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 your Regional Migratory Bird Permit Office by the due date. 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.
If your permit authorized disturbance at a nest, was the nest successful this year (i.e., were any young fledged)? Yes

No

Unknown

TYPE OF EAGLE USE AREA (nest, communal roost, or foraging area):
Note: Please use a separate supplemental sheet for each IEUA
DATE
TIME
NUMBER OF
OBSERVED BEHAVIOR
P – perched
IF– in flight
OF
OF
EAGLES
F – feeding
AB – agitated
MONITORING
DAY
OBSERVED
behavior
(Specify “A” for adult N – sitting on or
attending
nest
and “Y” for young

DESCRIPTION OF HUMAN ACTIVITY
AT TIME EAGLES WERE OBSERVED
(e.g., surveying; excavation; interior work, etc.)
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: ____________________________________________________________
Date:___________________________________
Signature of permittee/Principal Officer (No stamped signatures. Electronic signatures accepted.)

Date of signature (mm/dd/yyyy))

FWS Form 3-202-15 (Rev. 04/2022)
U.S. Department of the Interior

OMB Control No. 1018-0167
Expires ##/##/20##

Section A Supplemental Sheet

SUPPLEMENTAL PAGE#:

EAGLE TAKE ANNUAL REPORT

REPORT YEAR__________

PERMITTEE:__________________________________

PERMIT NUMBER:__________________

TYPE OF EAGLE USE AREA (nest, communal roost, or foraging area):
Note: Please use a separate supplemental sheet for each IEUA
DATE
EAGLES
OBSERVED

TIME
OF
DAY

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”

FWS Form 3-202-15 (Rev. 04/2022)
U.S. Department of the Interior

OMB Control No. 1018-0167
Expires ##/##/20##

Section B
B. Eagle injury and mortality reports must be generated through the Service’s online reporting system. Follow guidance provided by your
Regional Migratory Bird Permit Office with your permit on how to get an account and submit and generate eagle injury and mortality reports via
the system.

FWS Form 3-202-15 (Rev. 04/2022)
U.S. Department of the Interior

OMB Control No. 1018-0167
Expires ##/##/20##

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 assess 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. 1018-0167.

ESTIMATED BURDEN STATEMENT
We estimate public reporting for this collection of information averages:
Original submission - paper-based: 20 hours (reporting) and 20 hours (recordkeeping)
Original submission - electronic: 18 hours (reporting) and 20 hours (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 non-confidential summary and remaining documents may be
made available to the public under FOIA [43 CFR 2.26 – 2.33].