WS 12A Work Initiation Document for Wildlife Damage Management

Clear Form
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 5 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.

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
WILDLIFE SERVICES
1. WORK INITIATION DOCUMENT NUMBER

WORK INITIATION DOCUMENT FOR
WILDLIFE DAMAGE MANAGEMENT
2. STATUS
NEW

SECTION 1

OMB Approved
0579-0335
EXP: XX/XXXX

RENEWAL

3A. TYPE OF WORK INITIATION DOCUMENT (mark all that apply)

3B. ASSIGN TO THESE SPECIAL GROUPS
(1)

PRIVATE PROPERTY

NON-PRIVATE PROPERTY

TEMPORARY/CIVIL

ADJACENT LANDOWNER

AMENDMENT TO AN EXISTING WORK INITIATION DOCUMENT

(2)
(3)
(4)

4. COOPERATOR NAME (last, first, MI)

SECTION 2

5. COOPERATOR MAILING ADDRESS
6. COMMON NAME

7. COOPERATOR TELEPHONE NUMBER

8. OWNER OR REPRESENTATIVE NAME (if different from Cooperator)

9. OWNER OR REPRESENTATIVE TELEPHONE NUMBER

10. OWNER OR REPRESENTATIVE ADDRESS (if different from Cooperator)

SECTION 3

11. PROPERTY / LAND CLASS INFORMATION
COUNTY
PROPERTY
LAND CLASS

12. ADJOINING
PROPERTY WID NO.’s

13. TARGETED SPECIES

A.

A.

A.

F.

B.

B.

B.

G.

C.

C.

C.

H.

D.

D.

D.

I.

E.

E.

E.

J.

SECTION 4

STATE

ACRES

14. There are additional targeted species

TOTAL ACRES

(complete and attach WS Form 12 Addendum)

15. In consideration of the benefits to be derived from the proper management of damage caused by those species listed in Item 13 (and Item 14 if applicable), I, the
undersigned Cooperator or Cooperator’s representative, do hereby give my consent and concurrence to the Animal and Plant Health Inspection Service (APHIS) (to
include its officials, employees, and agents) to use, upon lands owned, leased, or otherwise controlled by me, and identified by this Work Initiation Document, the
following methods and devices (COMPONENTS):
A.
D.

B.

C.

E.

F.

SECTION 5

17. I, the Cooperator or Cooperator’s representative, have been informed of the methods and the manner in which the control materials and devices listed in Section 4
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 to prevent injury to animal life other than those listed in Section 3, Item 13 (and Item 14, if applicable); guard against the
mishandling of control devices and materials; and exercise due caution and proper judgment in all wildlife damage management operations. I understand that APHIS
WS will maintain restricted use pesticide application records on applications made under the Work Initiation Document, and that APHIS WS will provide copies of the
records or record information promptly upon the property owner’s or cooperator’s request. I understand that APHIS WS may collect Global Positioning System (GPS)
coordinates at the project site as part of component or activity tracking or as wildlife disease monitoring or research data. As a Lessee, the Cooperator agrees that the
lease is current and will remain so while APHIS WS conducts operational activities on the property, and will notify WS if the lease expires or is canceled. The Lessee
agrees to notify the landowner about any methods or devices (components) in use by APHIS WS on the property.

SECTION 6

16. There are additional components (complete and attach WS Form 12 Addendum)

18. In consideration of these understandings and of the benefits to be derived, I, the Cooperator or Cooperator’s representative, agree to take reasonable precautions to
prevent injury to livestock and other domestic animals; assume responsibility for injury to my property under my control when said injury is not the result of negligence on
the part of APHIS; assist in maintaining such warning signs as APHIS may place for the purpose of notifying persons entering onto such lands of the possible hazards
associated with wildlife damage management measures in use thereon; and to give adequate warning of these possible hazards to persons I authorize to enter onto
such lands. Further, in recognition of the benefits to be derived from the use of specified methods and devices authorized by this Work Initiation Document, I, the
cooperator or cooperator’s representative, agree not to concurrently use or allow to be used upon lands covered by this Work Initiation Document any toxic material that
might reasonably be expected to take a species listed above in Section 3, Item 13 (and Item 14, if applicable), unless such use of said toxicant is agreed to by APHIS in
writing.

19. SPECIAL CONSIDERATIONS

20A. LANDOWNER, LESSEE, OR ADMINISTRATOR NAME AND TITLE

20B. SIGNATURE

20C. DATE

21A. APHIS REPRESENTATIVE NAME

21B. SIGNATURE

21C. DATE

21D. APHIS REPRESENTATIVE TELEPHONE NUMBER

21E. STATE OFFICE ADDRESS

WS FORM 12A
OCT 2017

PRIVACY ACT NOTICE
5 U.S.C. 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
7 U.S.C. 8351 to 8353, and 16 U.S.C. 667, authorizes officers, agents, and employees of the United States Department of Agriculture (USDA), Animal
and Plant Health Inspection Service (APHIS), Wildlife Services (WS) 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.
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
(1) To cooperative Federal, State, Tribal, and local government officials, employees, or contractors and other parties as necessary to carry out the
program; and other parties engaged to assist in administering the program. Such contractors and other parties will be bound by the nondisclosure
provisions of the Privacy Act. This routine use assists the agency in carrying out the program, and thus is compatible with the purpose for which the
records are created and maintained;
(2) To the appropriate agency, whether Federal, State, local, Tribal, 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;
(3) 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;
(4) 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;
(5) 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 of 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;
(6) To USDA contractors, partner agency employee or contractors, or private industry employed to identify patterns, trends, or anomalies indicative of
fraud, waste, or abuse;
(7) To land management agencies, such as the Bureau of Land Management and the U.S. Fish and Wildlife Service, relating to wildlife damage on
grazing allotments;
(8) To consumer reporting agencies in accordance with 31 U.S.C. 3711(e);
(9) To Federal, State, Tribal, and local regulatory agencies and their employees and contractors who collaborate with Wildlife Services in implementation
of, or agencies that regulate, wildlife management projects or programs, or who have an interest in, or regulate, animal or public health, or national
security;
(10) To Federal or State Government-level representatives of the U.S. Environmental Protection Agency, in compliance with the Federal Insecticide,
Fungicide, and Rodenticide Act (FIFRA) mandate in 7 U.S.C. 136(f, and i thru l), of the location on a cooperator’s property where certain regulated
pesticide devices are deployed or regulated pesticides are applied; and
(11) To the National Archives and Records Administration (NARA) or to the General Services Administration for records management inspections
conducted under 44 U.S.C. 2904 and 2906.

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 12A,
Work Initiation Document For Wildlife Damage Management
NOTE: A WS Form 12A Work Initiation Document (WID) is required to be signed by a Cooperator for all properties worked by Wildlife
Services (WS). The WID and the WID agreement in WS Management Information System (MIS) expire 5 years after the Cooperator
signature date. To renew a WID agreement for another 5 years, a new WS Form 12A is required to be signed by the Cooperator, and
everything on the WID agreement in MIS must match the corresponding items on the WS Form 12A.
NOTE: An expanded and detailed set of instructions for the WID is available in MIS. Employees should study the detailed version
until familiar with completing the WID.
SECTION 1 – Basic WID Identification and Type
1. Entering the WID document number is optional. Contact your MIS Data Technician to obtain this number if one is needed.
2. Mark only one box, selecting New (agreement) or Renewal (of existing agreement).
3. A WID may have more than one type of work characteristic. Mark all applicable boxes indicating this WID’s type of work.
SECTION 2 – Cooperator Information
4. Enter the name of the Cooperator as it appears on the Cooperative Service Agreement, Cooperative Service Field Agreement,
Memorandum of Agreement or Understanding, or as it appears in the Cooperator’s business references.
5. Enter the Cooperator’s mailing address with street or P.O. box, city, state, and ZIP code. This may be the permanent address, mailing
address, home address, or business/office address.
6. Enter the common name of the Cooperator’s business, farm, or ranch, if applicable.
7. Enter the Cooperator’s telephone number including the area code. It may be a landline or mobile telephone number.
8. Enter the name of the owner or Cooperator’s representative if it is different from the Cooperator’s name.
9. Enter the property owner’s or property owner representative’s telephone number including area code.
10. Enter the property owner’s address (or property owner representative’s work address if this is a business or a non-private agreement),
including the ZIP code. If the Cooperator’s address in Item 5 is also the owner’s address, skip this step.
SECTION 3 – Property Information, Location of Work, and Species Being Addressed
11. In this subsection, record the state and counties for the site(s) where the work is being performed for the cooperator. Include for each
property the land class being worked on and the number of acres for the land class. Usually, only one land class can be recorded per property.
If there is more than one land class on a property, identify each of them separately (e.g. Property: Smith #1, Land Class Private; Smith #2,
Land Class County/City). Record the total acres by summing all entries in the “Acres” column.
12. If the WID allows work on an adjoining property as part of the project, additional WIDs signed by the adjoining landowners/ managers must
be obtained. The WID document numbers for the adjoining properties go in this subsection. If WID numbers are not assigned, list the name of
the other land owners/managers instead of numbers.
13. List the full common names of the targeted species as found in MIS. Review MIS Reference Files for accuracy.
14. If more than 10 species are targeted, mark this box and list the additional species on WS Form 12 Addendum. The WS Form 12A also
requires an original signature. Ensure the WS Form 12 Addendum is attached to this WS Form 12A.
SECTION 4 – Component Use Information
15. List the components that will be used in the project. They must be annotated exactly as they appear in the MIS component list. Do not list
any activities (e.g., shooting, trapping, etc.).
16. If more than six components are entered, mark this box and list the additional components on WS Form 12 Addendum. The WS Form 12
Addendum also requires an original signature. Ensure the addendum is attached to this WS Form 12A.
Section 5 – Work Initiation Considerations, WS Responsibilities
17. The Cooperator is required to read this section, or alternatively have it read to him/her, before signatures are affixed to the WID.
Section 6 – Work Initiation Considerations, Cooperator Responsibilities
18. The Cooperator is required to read this section, or alternatively have it read to him/her, before signatures are affixed to the WID.
19. Special Considerations - If any special considerations are agreed to for this project, enter them in Item 19. They may also be entered in
the MIS in the Agreement Remarks or the Property Comments fields.
20, 21. Signatures/Dates – To complete the form, both the Cooperator’s authorized signer and the APHIS Representative (WS employee)
print their names, sign in ink, and date the WS Form 12A. The WS employee also enters a contact telephone number and the State Office’s
address.
The WS employee is responsible for ensuring the Cooperator or authorized representative receives a copy of the WS Privacy Act Notice.