Form WS 92 WS 92 Livestock Protection Collar (LPC) Accident Report

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 1.00 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.

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
WILDLIFE SERVICES

OMB Approved
0579-0335
EXP: XX/XXXX

LIVESTOCK PROTECTION COLLAR (LPC)
ACCIDENT REPORT

Report all accidents involving contamination or poisonings other than contamination or poisoning of collared animals or coyotes. This form is to be completed and mailed DATE OF ACCIDENT
to the State Director, USDA APHIS BSS TSS, 4700 River Road, Unit 150, Riverdale, MD 20737, within three working days whenever compound 1080 is accidentally
exposed to the environment. In addition, report all poisonings of threatened or endangered species, humans, domestic animals (except LPC-collared animals) or nontarget wild animals within three days to the State Director. It is the responsibility of USDA APHIS BSS TSS to contact the Environmental Protection Agency (EPA).

SECTION I - ACCIDENT INFORMATION
1. NAME OF PERSON PREPARING REPORT (other than injured person or applicator)

2. ADDRESS OF PERSON PREPARING REPORT (provide accurate street address; do not
use P.O. box numbers)

ACCIDENT LOCATION
3. ADDRESS OF ACCIDENT LOCATION (provide accurate street address; do not use P.O.

4. EXPLICIT LOCATION OF ACCIDENT (pasture, shed, corral, etc.)

box numbers)

5. NAME OF LANDOWNER OR LESSEE WHERE ACCIDENT OCCURRED

7. WAS ACCIDENT SITE TREATMENT AREA
ADEQUATELY POSTED WITH WARNING SIGNS?

8. ACCIDENT RESULTED IN POISONING OF:

9. MODE OF POISONING:

(“X” all that apply)

(Use restriction number 10 for the LPC required standards for
posting signs. In your judgment, were these standards met?)

YES

6. ADDRESS OF LANDOWNER OR LESSEE (if different from accident site)

NO

HUMAN (also complete Sections II and IV)

INGESTION

ANIMAL (also complete Sections III and IV)

UNKNOWN

10. IF CONTENTS OF LPC WERE ACCIDENTALLY LEAKED INTO THE
ENVIRONMENT, WHICH OF THE FOLLOWING ITEMS WERE EXPOSED?

ABSORPTION

11. WHICH METHOD WAS INVOLVED

(“X” all that apply)

CLOTHING

FOOD

WATER

BUILDING

GROUND

OTHER (specify)

VEHICLE

STORAGE

USE OF LPC

TRANSPORTATION

REMOVAL

DISPOSAL

OTHER (specify)

SECTION II - INJURED PERSON INFORMATION
(if more than two people are injured, attach additional sheets)

12. NAME AND ADDRESS OF INJURED PERSON

15. DID THE PERSON SEE A DOCTOR?
YES

22. DID THE PERSON SEE A DOCTOR?

WS FORM 92
NOV 2016

YES
20. AGE (in years)

NO

21. OCCUPATION

IF YES, PROVIDE THE NAME AND ADDRESS OF THE DOCTOR

IF YES, PROVIDE THE NAME AND ADDRESS OF THE HOSPITAL

NO

24. WAS FIRST AID ADMINSTERED ON SITE?
YES

IF YES, PROVIDE THE NAME OF THE PERSON ADMINISTERING FIRST AID 18. WAS EMETIC USED?

NO

23. WAS THE PERSON HOSPITALIZED?
YES

IF YES, PROVIDE THE NAME AND ADDRESS OF THE HOSPITAL

NO

19. NAME AND ADDRESS OF INJURED PERSON

YES

IF YES, PROVIDE THE NAME AND ADDRESS OF THE DOCTOR

NO

17. WAS FIRST AID ADMINSTERED ON SITE?
YES

14. OCCUPATION

NO

16. WAS THE PERSON HOSPITALIZED?
YES

13. AGE (in years)

NO

IF YES, PROVIDE THE NAME OF THE PERSON ADMINISTERING FIRST AID 25. WAS EMETIC USED?
YES

NO

SECTION III - POISONED ANIMAL INFORMATION
26.

27. IS ANIMAL AN ENDANGERED OR
THREATENED ANIMAL?
COMMON AND SCIENTIFIC NAME
OF INJURED ANIMAL(S) INVOLVED IN THE ACCIDENT

28.
DID ANIMAL SURVIVE INJURY?

(50 CFR PART 17.11)

YES

NO

YES

NO

A.
B.
C.
D.
29. WERE ANIMALS TREATED BY A VETERINARIAN?
YES

30. IF ANIMAL WAS TREATED, PROVIDE NAME AND ADDRESS OF VETERINARIAN

NO

SECTION IV - DESCRIPTION OF ACCIDENT
(if more space is needed, attach additional sheet(s))

31. PROVIDE A BRIEF NARRATIVE OF THE ACCIDENT INCLUDING DETAILS OF THE TIME, SEQUENCE OF EVENTS, OTHER PERSONS INVOLVED, AND OTHER
FACTS THAT WOULD PROVIDE A REVIEWER OF THIS FORM A GOOD WORKING KNOWLEDGE OF THE CIRCUMSTANCES SURROUNDING THE ACCIDENT.

My signature indicates that the facts depicted in this report are accurate to my knowledge.
32. PREPARER TITLE

33. PREPARER SIGNATURE

34. DATE SIGNED

My signature indicates that I am aware of the accident occurrence and the facts depicted are accurate to the best of my knowledge.
35. DISTRICT SUPERVISOR SIGNATURE

SAME AS PREPARER

WS FORM 92 REVERSE

36. DATE SIGNED

37. STATE DIRECTOR SIGNATURE

SAME AS PREPARER

38. DATE SIGNED

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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
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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 section 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 State- or Federal Government-level representatives of the U.S. Environmental
Protection Agency, in compliance with the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA) mandate (FIFRA
Sec. 8, 7 U.S.C. 136f, and FIFRA 7 U.S.C. 136i-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.