WS 12C Work Initiation Document for Management of Wildlife Dama

Clear Form
OMB Approved
0579-0335
EXP: XX/XXXX

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. COUNTY AND WS EMPLOYEE INFORMATION
AGR TYPE:

T

C

AE

AP

2. MARK ALL SPECIES TO BE MANAGED

SC

COUNTY _______________________ ST _________
CIVIL AGREEMENT NO.

WORK INITIATION DOCUMENT FOR
MANAGEMENT OF WILDLIFE DAMAGE
ON URBAN PROPERTIES

______________________

LAND CLASS _______________ ACRES _________

3. MARK ALL APPROVED COMPONENTS TO BE
USED ON THIS PROJECT

STRIPED SKUNK

MOUNTAIN LION

CAGE TRAP

OPOSSUM

FERAL PIGEONS

FIREARM

RACCOON

E. STARLINGS

CATCH POLE

A – CHLORALOSE
INAD NUMBER

COYOTE

W-TAILED DEER

ROCKET/CANNON NET

EMPLOYEE NAME

__________________________

BLACK BEAR

CANADA GEESE

NET GUN

EMPLOYEE NAME

__________________________

OTHER (list)

OTHER (list)

EMPLOYEE NAME

__________________________

OTHER (list)

OTHER (list)

EMPLOYEE NAME

__________________________

OTHER (list)

OTHER (list))

4. I, the Cooperator, have been informed of the manner in which the damage management components listed in Section 3 will be used, and of the possible hazards associated with their use. I understand
that the Animal and Plant Health Inspection Service (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 2 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

5. SPECIAL CONSIDERATIONS
6A. NAME AND SIGNATURE OF LANDOWNER, LESSEE, OR
ADMINISTRATOR

6B. ADDRESS AND TELEPHONE NUMBER

6C. DATE

7A. NAME, TITLE, AND SIGNATURE OF APHIS REPRESENTATIVE 7B. ADDRESS AND TELEPHONE NUMBER

7C. DATE

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 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.

WS FORM 12C (OCT 2017)

Instructions for Completing WS Form 12C
Work Initiation Document for Management
of Wildlife Damage on Urban Properties
1. County and Wildlife Services (WS) Employee Information
a. Select the agreement type by marking the appropriate box:
T
C
AE
AP
SC
b.
c.
d.
e.

-

Temporary
Continuation Form
Amendment of an Existing Agreement
Addendum to a Private Agreement
Special Considerations listed in Item 5

Enter the county identifier, or
Civil Agreement number.
Enter the land class and number of 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.

2. Targeted Species. Mark all applicable boxes indicating the species that will be targeted in the damage management actions. If “OTHER”
is marked, enter the species’ common name.
3. Components to be Used. Mark all applicable boxes indicating the 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 Environmental Protection Agency (EPA) or State registration number. If “OTHER” is
marked, list chemicals by name and provide their EPA or Food and Drug Administration (FDA) registration numbers.
4. Have the Cooperator read, or alternatively read to him or her, the Cooperator’s responsibilities.
5. Special Considerations. Enter any special considerations agreed upon between the Cooperator and Wildlife Services.
6. Landowner, Lessee, or Property Administrator Information. Enter the landowner’s, lessee’s, or property administrator’s full name,
address, and telephone number and have him/her sign and date the form.
7. APHIS Wildlife Services Representative Information. Enter the APHIS WS Representative’s full name, address, and telephone number,
and have him/her sign and date the form.
Provide a copy of the WS Form 12C to the Cooperator and distribute remaining copies as directed by the WS State Director.