WS Form 12C Work Initiation Document for Wildlife Damage Management

OMB Control No. 0579-XXXX

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE (APHIS)
WILDLIFE SERVICES (WS)

WORK INITIATION DOCUMENT FOR MANAGEMENT OF WILDLIFE DAMAGE ON URBAN PROPERTIES
A. COUNTY AND WS EMPLOYEE INFORMATION:

STRIPED SKUNK

MT. LION

County _________________________ST________

OPOSSUM

FERAL PIGEONS

Civil Agreement No. ________________________

RACCOON

E. STARLINGS

Land Class _________________Acres__________

COYOTE

W-TAILED DEER

Employee Name____________________________

BLACK BEAR

CANADA GEESE

Employee Name____________________________

OTHER (list)___________________________

AGR. TYPE:

T

C

AE

AP

Employee Name____________________________
Employee Name____________________________

SC

B. MARK ALL SPECIES TO BE MANAGED

OTHER (list)___________________________
OTHER (list)___________________________

C. MARK ALL APPROVED COMPONENTS
TO BE USED ON THIS PROJECT
CAGE TRAP
FIREARM

A - CHLORALOSE
(INAD #_____________)

CATCH POLE
ROCKET/CANNON NET
NET GUN
OTHER (list)________________________
OTHER (list)_________________________

D. I, the Cooperator, have been informed of the manner in which the damage management components listed in Section C will be used, and of the possible hazards
associated with their use. I understand that APHIS, to include its officers, employees, and agents will; exercise reasonable precautions to safeguard all persons and to
prevent injury to animal life other than those listed in Section B above; guard against the mishandling of control devices and materials; and exercise due caution and
proper judgment in all control operations.
In consideration of these understandings and of the benefits to be derived, I, the cooperator, agree: to take reasonable precautions to prevent injury to domestic
animals; to assume responsibility for injury to my property or to property under my control, when said injury is not the result of negligence on the part of APHIS; and
that no traps should be left actively deployed and unmonitored over weekends or holidays.
THIS WORK INITIATION DOCUMENT MAY BE REVOKED BY EITHER PARTY BY A 30 – DAY WRITTEN NOTICE
E. SPECIAL CONSIDERATIONS:
F. THE FACILITIES / PROPERTIES / NAME OF PERSON(S) / ENTITY INDICATED IN THIS WORK INITIATION DOCUMENT (mark one box):
Are / is registered in the State as a business, corporation, LLC, LLP, or LP

Is a government agency or entity

Represent(s) a sole-proprietorship or dba of a sole proprietorship

Is a private citizen with no business status

G. NAME OF LANDOWNER, LESSEE, OR ADMINISTRATIOR

ADDRESS AND PHONE NUMBER

DATE

_____________________________________________________________
H. SIGNATURE (Landowner, Lessee, or Administrator)
________________________________________________________________________
_____________________________________________________________ ADDRESS AND PHONE NUMBER
DATE
I. SIGNATURE AND TITLE (APHIS Representative)

Privacy Act Notice
Title 5. United States Code, Section 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
Title 7, United States Code (USC), Section 426-426c, and Title 16 USC, Section 667, authorizes officers, agents, and employees of the USDA, APHIS, Wildlife
Services 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. Further, 5 USC 552a authorizes USDA, APHIS, Wildlife Services to collect information
about private individuals for its system of records pursuant to the conduct of program activities with those private individuals.
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
The routine uses which may be made of the information are: Routine use 1 provides for disclosure to the cooperative State government officials, employees, or
contractors, as necessary to carry out the program.
Routine use 2 provides for the referral to the appropriate agency, whether Federal, State, local, 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;
Routine use 3 permits disclosure 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;
Routine use 4 permits disclosure 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;
Routine use 5 permits disclosure to a congressional office in response to a request from that office for the record of an individual made at the request of that individual;
Routine use 6 permits disclosure to the Comptroller General or any of his authorized representatives in the course of their duties at the Government Accountability
Office; and
Routine use 7 permits disclosure to a consumer reporting agency in accordance with section 31 U.S.C. 3711(e).
Routine use 8 permits disclosure 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 or 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.
Effects of Failure to Furnish Information
Failure to provide the solicited information will not subject you to penalties or adverse consequences.

According to the Paperwork Reduction Act of 1995, no persons are 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-XXXX. The time required to complete
this information collection is estimated to average .021 minutes/hours 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.

WS FORM 12C (2006)

Instructions For Completing WS Form 12 C – Work Initiation Document for Management
of Wildlife Damage on Urban Properties
Refer to MIS Field Handbook for additional guidance in completing this form.
Item
A
County and WS Employee Information:
Enter the agreement type by marking the appropriate box to indicate: “T” = Temporary,
“C” = Continuation Form, “AE” = Amendment of an Existing Agreement, “AP” =
Addendum to a Private Agreement, or “SC” = Special Considerations listed in Section E.
Enter the county identifier or Civil Agreement number
Enter the land class
Enter acres being protected. If less than one acre, enter “1”.
Enter the name of the WS employee(s) conducting work on this project, or the WS
employee to whom the responsibility of this project is assigned.
B

Species to be targeted - Mark the appropriate box(es) to indicate the species that will be
targeted in the damage management actions. If “OTHER” is marked, list by species
common name

C

Components to be Used - Mark the appropriate box(es) to indicate components to be
used in the project. If Alpha Chloralose is to be used, mark the box and enter the INAD
Number for the formulation to be used. If DRC-1339 is listed, or another chemical, enter
the EXACT formulation to be used by recording the EPA or State registration number. If
“OTHER” is marked, list by name and provide EPA or FDA registration number for any
chemicals listed.

D

Have the Cooperator read, or read for the Cooperator, the information in this section.

E

Special Considerations: Any special considerations agreed upon between the Cooperator
and WS must be entered in this section.

F

Cooperator representative marks one of the boxes in this section which identifies whether
Cooperator is a business or a private citizen. The following definitions should be used to
explain to the Cooperator what each of the terms associated with the check boxes mean:
a. Company: A proprietorship, partnership, corporation, or other form of enterprise that
engages in business.
b. Corporation: A legal entity that is separate and distinct from its owners.
c. LLC: Limited Liability Company (or Limited Liability Partnership)
d. LLP: Limited Legal Liability Partnership (or Limited Liability Partnership)
e. LP: Limited Partnership
f. dba: “doing business as” – a formal notice that an individual, company or
organization is conducting business under a different name.
Enter the name of the landowner, lessee, or administrator of the property where this
project will occur.

G

WS FORM 12C (2006)

H

I

Enter the address and phone number of the entity named in appropriate box to the right.
Have the entity identified in G as the landowner, lessee, or administrator sign on this
signature line and place a date in the “date” block to the right.
The APHIS (WS) representative signs and enters title, duty station or office address,
phone number and date in this section.
Provide copies to the Cooperator, and as directed by the WS State Director.

WS FORM 12C (2006)