WSForm 30 WS Assistance 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 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 .035 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.	OMB Approved 0579-0335 EXP XX/XXXX
Wildlife services Assistance request
1.DISPOSITION____________________________________________________________________________________ _________________________________________________________________________________________________ 2.a) SEND/PROVIDE ________________________________________________________________________________ _____________________________________________ b) DATE SENT/PROVIDED______________________________ 3.a) NAME OF REQUESTER__________________________________________________________________________ b) ADDRESS ______________________________________________________________________________________ c) PHONE _____________________ d) OTHER DIRECTIONS_______________________________________________ 4.a) LOCATION _______________________b) PAR c) URB d) RUR e) ADDITIONAL FORM 5.a) DATE ___________________ b) TIME SPENT ________________ c) PROJECT TYPE_______________________ 6.a) DEPREDATING SPECIES _____________________ b) #LEAFLETS ___________ c) #PARTICIPANTS__________ DAMAGE DATA 7.a) RES #1_________________ b) INCID/QTY AFFECTED __________c) DAMAGE TYPE_______________ d) DOLLAR VALUE _______________ e) REPORTED f) VERIFIED g) N/A 8.a) RES #2_________________ b) INCID/QTY AFFECTED __________c) DAMAGE TYPE_______________ d) DOLLAR VALUE _______________ e) REPORTED f) VERIFIED g) N/A DEPREDATION PERMITS 9. FEDERAL :a) NEW b) RENEWAL c) RECOMMENDED d) NOT RECOMMENDED 10. STATE: a) RECOMMENDED b) ISSUED c) REFFERRAL AGENCY__________________________ CHEMICAL CONTROL DATA 11.a) RES #1 _____________ b) METH ___________ c) QTY _______ d) DEMO e) DIST f) SOLD 12.a) RES #1 _____________ b) METH ___________ c) QTY _______ d) DEMO e) DIST f) SOLD 13.DEPREDATING SPECIES QUANTITY_____________ EQUIPMENT DATA 14.a) METHOD ________________________________ 1) QTY_____ 2) DIST 3) LOAN 4) SOLD b) METHOD __________________________________1) QTY_____ 2) DIST 3) LOAN 4) SOLD c) METHOD __________________________________1) QTY_____ 2) DIST 3) LOAN 4) SOLD RECOMMENDATIONS 15. a) RESOURCE# 1________________________ b) METHOD __________________ c) REC d) CEM 16. a) RESOURCE# 1________________________ b) METHOD __________________ c) REC d) CEM 17. a) RESOURCE# 1________________________ b) METHOD __________________ c) REC d) CEM 18. a) RESOURCE# 1________________________ b) METHOD __________________ c) REC d) CEM 19. a) RESOURCE# 1________________________ b) METHOD __________________ c) REC d) CEM COMMENTS 20. ______________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 21. WS EMPLOYEE ____________________________________________ 22. ENTERED IN DATA BASE

WS FORM 30

FEB 2011

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.

Instructions for completing WS Form 30 – Wildlife Services Request

This form is used to collect information about a person who has requested assistance from WS about wildlife damage. This information will usually be collected by telephone from requesters who call a WS office seeking assistance. The information captured includes the location of the problem, name of caller, phone number and data about the nature of the damage and the species involved. It also collects information about what recommendations might be provided for resolving the damage. If the number of items to be reported exceeds the capacity of this form, a new form should be filled out for those additional items. Example: The form is designed to capture information about one species (Item 6a). If the requester reports damage from two separate species, a form should be filled out for each.

The WS employee filling out this form is instructed to refer to the MIS Help Files for further information about entries.

1. Keep short notes on this line about what stage of the process you are in with the customer. Example: an entry such as “called, left message on voice mail” could mean you called the customer back but he/she was not available and you left a message on the voice mail. Messages to yourself about commitments to loan equipment or distribute supplies could be entered here also.

2a&b. After discussing the problem with the customer, you may have agreed to send a wildlife damage management leaflet or some material to the person, or you may have agreed to provide a damage control device, tool, or supply. This line is to be used to instruct the WS employee (or to remind yourself) to send or provide such items to the requester and to post the date that it was sent or provided.

3a-c. Enter the name, address, phone number of the requester.

3d. If a trip to the requesters property to look at the problem is planned, you may need additional directions beyond the address. They are entered here. Example: if the requester lives at one site and the wildlife damage is occurring at another, you may need directions or an address for that property.

4a. Enter the county or city where the requester lives or where the property receiving damage is located.

4b. (= Participant): Mark this box if you are helping a fellow employee with this project or if you want to record that the project is not yet completed. When this project is completed DO NOT mark this bubble on the last form you turn in for it.

4c-d. If this project is in an urban environment mark “URB.” If in a rural environment, mark “RUR.” Refer to your MIS Field Handbook for definitions of these two environments.

4e. Mark this block if this is an additional form to capture more information about a requester than you could enter on the original form. Refer to your MIS Field Handbook for guidance on what information is to be entered into an “Additional Form.”

5a. Enter the date you recorded this information.

5b. Enter the time spent on the project (optional)

5c. Enter the project type.

6a. Enter the depredating species involved in the damage.

6b. Enter the number of leaflets sent to the requester

6c. Enter the number of requester participants involved in this project.

7a. Enter the resource type affected by the reported wildlife damage.

7b. Enter the number of incidents of damage or the quantity of the resource affected by the damage.

7c. Enter the damage type for this project.

7d. Record the dollar value of loss to the requester from the reported damage.

7e-g. Mark the appropriate block to indicate whether the dollar value of loss was “reported” by the requester, “verified” by the WS employee, or “not available” from any source.

8a. This line is to be used to record a second resource type affected (if applicable).

8b-g. Refer to instructions for # 7b-g.

9a-b. If a federal permit is discussed as a means to address the damage problem, record whether the permit is to be a “NEW” permit or “RENEWAL” of an existing one.

9c-d. Notate whether the permit was recommended or not recommended by marking the appropriate box.

10a-b. If a state permit is recommended by WS, mark item a; if a state permit is issued by the appropriate state agency representative mark the “ISSUED” box.

10c. If this is a personal consultation or a Written/telephone consultation, record the agency who referred the call to you OR the agency you referred the call to (optional; check with your state director).

11-12a-f. Record chemical control information in these lines. Item 11 is for entries about chemical control associated with Resource #1 (Item 7a) and item 12 is for entries about chemical control associated with Resource #2 (Item 8a). Record each resource in a, any chemical method provided to the requester in b, the quantity in c, whether you demonstrated the method (d), loaned (e) or sold (f) it to the requester.

13. (Optional) Record the numbers of individuals of the depredating species which you listed in 6a.

14a-c. Use these lines to record information about any equipment related to this project. In “a” record the equipment by method name (example cage trap, leghold, conibear, neck snare, gas exploder, pyrotechnics), in “b” record the quantity provided, in “c”, “d”, or “e” mark the appropriate box to indicate whether you distributed, loaned or sold the equipment to the requester. You have space to record information about 3 pieces of equipment in this item.

15-19. Enter recommendations made in these lines. Record which resource the recommendation was made for in item “a.” Record the method or component recommended by WS or already used by the requester in item “b.” Record by marking the appropriate block whether the method you recorded in “b” was recommended (c: REC) or employed by the requester (d: CEM).

20. Record any comments about this project you may have in this line

21. Print your name in this line

22. When you have entered this information into the MIS database, mark this block