Form 3-202-15 Eagle Take (Monitoring and Reporting) Annual Report

U.S. FISH & WILDLIFE SERVICE - MIGRATORY BIRD PERMIT OFFICE
Return to: U.S. Fish and Wildlife Service (USFWS)
Click here for addresses.

EAGLE TAKE (50 CFR 22.26) - ANNUAL REPORT
PERMITTEE: _____
ADDRESS: _

_____________________________________

PERMIT NUMBER:_______________________________

___________________________________________

REPORT FOR CALENDAR YEAR*: ________________
*Programmatic take only
REPORT DUE DATE: _____________________________

_______________________________________________________
City

State

Zip Code

 Check here if reporting a change of name, address, or contact information

PHONE: ___________________________ Email: ______________________________

INSTRUCTIONS: Use section A (pp 1-2) to report eagle observations when monitoring for possible disturbance. Use section B (pp 3-4) to report eagle injuries and
mortality. Type or print the information requested below for each Important Eagle-Use Area (IEUA) identified on your permit during the year covered by this report and return the
completed report to the above address by the due date. Use of this form is not mandatory, but the same information must be submitted, including a signed certification statement. Filing an
annual report is a condition of your permit. Failure to file a timely and accurate report can result in permit suspension. Accurate reporting will play an essential role in future eagle
management.
Instructions for Section A: Continue data entry for each IEUA on additional Sec A Supplemental Sheet. (You may need to make or print copies of the blank supplemental sheet.)
Use a separate supplemental sheet for each IEUA identified on your permit.

A.

IMPORTANT EAGLE-USE AREA:
(1) If your permit authorized disturbance at a nest, was the nest successful in this past year (i.e., were any juveniles eagles fledged)? Yes  No  Unknown 
(2) If more than one of one type of IEUA is identified on your permit, designate which nest (or roost or foraging area) data applies to.
DATE
TIME
NUMBER OF
OBSERVED BEHAVIOR
DESCRIPTION OF HUMAN ACTIVITY
P – perched
IF– in flight
EAGLES
OF DAY
EAGLES OBSERVED
AT TIME EAGLES WERE OBSERVED
F – feeding
N – sitting on or
(If in large numbers, please
(e.g., surveying; excavation; interior work, etc.)
OBSERVED
estimate)

AB – agitated behavior

attending nest

If activity is completed, enter “Completed”

CERTIFICATION: I certify that the information in this report is true and correct to the best of my knowledge. I understand that any false statement herein may subject me to the
criminal penalties of 18 U.S.C. 1001.
________________________________________________________
Signature of permittee/principal officer. (No photocopied or stamped signatures)
Form 3-202-15
(Rev 11/2017)

Date of signature (mm/dd/yyyy)
OMB Control No. 1018-0022

Expires XX/XX/XXXX

Section A Supplemental Sheet
EAGLE TAKE ANNUAL REPORT

REPORT YEAR__________

SUPPLEMENTAL PAGE #:____

PERMITTEE:__________________________________

PERMIT NUMBER:__________________

IMPORTANT USE AREA :
Identify nest, communal roost, or foraging area. Use a separate supplemental sheet for each IUA
DATE
EAGLES OBSERVED

Form 3-202-15

TIME
OF DAY

(Rev 11/2017)

NUMBER OF
EAGLES
OBSERVED
(If in large numbers, please
estimate)

OBSERVED BEHAVIOR
P – perched
F – feeding
N – sitting on or
attending nest

IF– in flight
AB – agitated
behavior

DESCRIPTION OF HUMAN ACTIVITY
AT TIME EAGLES WERE OBSERVED
(e.g., surveying; excavation; interior work, etc.)
If activity is completed, enter “Completed”

OMB Control No. 1018-0022

Expires XX/XX/XXXX

Section B - Report of eagle injuries and mortality.
INSTRUCTIONS: Instructions for Section B: Report eagle injuries and mortality. Use a separate supplemental sheet for each discreet geographic area covered by your
permit (e.g. “South tract” or “Clark County” or “Management Area xxxx.” Continue data entry for each geographic area on an additional Sec B Supplemental Sheet. (You
may need to copy or print more blank supplemental sheets.
MAKE SURE YOU SIGN & DATE THE CERTIFICATION STATEMENT BELOW BEFORE YOU SUBMIT YOUR REPORT

B.

GEOGRAPHIC AREA OF REPORTING:
Identify project/activity area
DATE
DISCOVERED

SPECIFIC
LOCATION
(e.g. utility pole #xx)

SPECIES
Bald or Golden

Did you enter this data into a FWS electronic reporting system?  YES
 NO
If “yes” select the system:
 Avian Injury/Mortality Reporting System (AIMRS/ECOS)
 Bird Injury/Mortality Reporting System (BIMRS)
ADDITIONAL COMMENTS
STATUS OF EAGLE
DISPOSITION
Use this area to provide additional
Use:
Use:
“I” for injured,
“D” for dead, or
“C” for uninjured but caught or
trapped in equipment or
infrastructure

“NER” if sent to the National
Eagle Repository;
“PR” if transferred to permitted
eagle rehabilitator;
“R” if released;
“TA” if transferred to USFWS or
State agency;
Other (Please specify)

explanation, if needed, (e.g., name and
permit number of rehabilitator if you
entered “PER” under “DISPOSITION” ).

CERTIFICATION: I certify that the information in this report is true and correct to the best of my knowledge. I understand that any false statement herein may subject me to the
criminal penalties of 18 U.S.C. 1001.
___________________________________________________
Signature of permittee/principal officer. (No photocopied or stamped signatures)
Form 3-202-15 (Rev 11/2017)

Date of signature (mm/dd/yyyy)
OMB Control No. 1018-0022 Expires XX/XX/XXXX

Section B Supplemental Sheet
GEOGRAPHIC AREA OF REPORTING :
Identify project/activity area
DATE
DISCOVERED

Form 3-202-15

SPECIFIC
LOCATION
(e.g. utility pole #xx)

(Rev 11/2017)

SPECIES
Bald or Golden

Did you enter this data into a FWS electronic reporting system?  YES
 NO If “yes”
select the system:
 Avian Injury/Mortality Reporting System (AIMRS/ECOS)
 Bird Injury/Mortality Reporting System (BIMRS)?
ADDITIONAL COMMENTS
STATUS OF EAGLE
DISPOSITION
Use this area to provide additional
Use:
Use:
“I” for injured,
“D” for dead, or
“C” for uninjured but
caught or trapped in
equipment or infrastructure

“NER” if sent to the National Eagle
Repository;
“PR” if transferred to permitted eagle
rehabilitator;
“R” if released;
“TA” if transferred to USFWS or State
agency;
Other (Please specify)

explanation, if needed, (e.g., name and
permit number of rehabilitator if you entered
“PER” under “DISPOSITION.”

OMB Control No. 1018-0022

Expires XX/XX/XXXX

FEDERAL FISH AND WILDLIFE PERMIT REPORT

NOTICES
PRIVACY ACT STATEMENT
Authority: The information requested is authorized by the following: the Bald and Golden Eagle Protection Act (16 U.S.C. 668), 50 CFR 22; the Endangered Species Act (16 U.S.C. 1531-1544),
50 CFR 17; the Migratory Bird Treaty Act (16 U.S.C. 703-712), 50 CFR 21; the Wild Bird Conservation Act (16 U.S.C. 4901-4916), 50 CFR 15; the Lacey Act: Injurious Wildlife (18 U.S.C. 42),
50 CFR 16; Convention on International Trade in Endangered Species of Wild Fauna and Flora (TIAS 8249), 50 CFR 23; General Provisions, 50 CFR 10; General Permit Procedures, 50 CFR 13;
and Wildlife Provisions (Import/export/transport), 50 CFR 14.
Purpose: The collection of contact information is to verify the individual has an eligible permit to conduct activities which affect protected species. The information the individual provides helps
the FWS monitor and report on protected species and assesses the impact of permitted activities on the conservation and management of species and their habitats.
Routine Uses: The collected information may be used to verify an applicant’s eligibility for a permit to conduct activities with protected wildlife; to provide the public and the permittees with
permit related information; to monitor activities under a permit; to analyze data and produce reports to monitor the use of protected wildlife; to assess the impact of permitted activities on the
conservation and management of protected species and their habitats; and to evaluate the effectiveness of the permit programs. More information about routine uses can be found in the System of
Records Notice, Permits System, FWS-21.
Disclosure: The information requested in this form is voluntary. However, submission of requested information is required to process applications for permits authorized under the listed
authorities. Failure to provide the requested information may be sufficient cause for the U.S. Fish & Wildlife Service to deny the request.
PAPERWORK REDUCTION ACT STATEMENT
In accordance with the Paperwork Reduction Act (44 U.S.C. 3501), the U.S. Fish and Wildlife Service collects information necessary to monitor take and disposition of migratory birds, under the
applicable laws governing the requested activity, for which a permit is requested, and to respond to requests made under the Freedom of Information Act and the Privacy Act of 1974. Information
requested in this form is purely voluntary. However, submission of requested information is required in order to process applications for permits authorized under the above laws. Failure to
provide all requested information may be sufficient cause for the U.S. Fish and Wildlife Service to deny the 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 currently valid OMB control number. OMB has approved this collection of
information and assigned Control No. 1018-0022.
ESTIMATED BURDEN STATEMENT
Public reporting for FWS Form 3-202-15 is 30 hours for reporting and 10 hours for recordkeeping, including time for reviewing instructions, gathering and maintaining data and completing and
reviewing the form. Direct comments regarding the burden estimate or any other aspect of the form to the Service Information Clearance Officer, Fish and Wildlife Service, U.S. Department of
the Interior, 5275 Leesburg Pike, MS: BPHC, Falls Church, VA 22041-3803. Please do not send your completed form to this address.
FREEDOM OF INFORMATION ACT
For organizations, businesses, or individuals operating as a business (i.e., permittees not covered by the Privacy Act), we request that you identify any information that should be considered
privileged and confidential business information to allow the Service to meet its responsibilities under FOIA. Confidential business information must be clearly marked "Business Confidential" at
the top of the letter or page and each succeeding page and must be accompanied by a non-confidential summary of the confidential information. The non-confidential summary and remaining
documents may be made available to the public under FOIA [43 CFR 2.26 – 2.33].

Form 3-202-15

(Rev 11/2017)

OMB Control No. 1018-0022

Expires XX/XX/XXXX

Migratory Bird Regional Permit
Offices
FWS
REGION

Region 1

Region 2

Region 3

Region 4

Region 5

Region 6

AREA OF
RESPONSIBILITY
Hawaii, Idaho, Oregon,
Washington
Arizona, New
Mexico, Oklahoma,
Texas

Iowa, Illinois, Indiana,
Minnesota, Missouri,
Michigan, Ohio,
Wisconsin

Alabama, Arkansas, Florida,
Georgia, Kentucky, Louisiana,
Mississippi, North Carolina,
South Carolina, Tennessee,
Virgin Islands, Puerto Rico
Connecticut, District of
Columbia, Delaware,
Maine, Maryland,
Massachusetts, New
Hampshire, New Jersey,
New York, Pennsylvania,
Rhode Island, Virginia,
Vermont, West Virginia
Colorado, Kansas, Montana,
North Dakota, Nebraska,
South Dakota, Utah,
Wyoming

Region 7

Alaska

Region 8

California, Nevada

MAILING
ADDRESS

CONTACT
INFORMATION

911 N.E. 11th Avenue
Portland, OR 97232-4181

Tel. (503) 872-2715
Email permitsR1MB@fws.gov

P.O. Box 709
Albuquerque, NM 87103

Tel. (505) 248-7882
Email permitsR2MB@fws.gov

5600 American Blvd. West
Suite 990
Bloomington, MN
55437-1458

Tel. (612) 713-5436
Email permitsR3MB@fws.gov

1875 Century Blvd., NE
Atlanta, GA 30345

Tel. (404) 679-7070
Email permitsR4MB@fws.gov

300 Westgate Center Drive
Hadley, MA 01035-0779

Tel. (413) 253-8643
Email permitsR5MB@fws.gov

P.O. Box 25486
DFC(60154)
Denver, CO 80225-0486

Tel. (303) 236-8171
Email permitsR6MB@fws.gov

1011 E. Tudor Road
(MS-201)
Anchorage, AK
99503

Tel. (907) 786-3693
Email permitsR7MB@fws.gov

2800 Cottage Way
Room W-2606
Sacramento, CA 95825

Tel. (916) 978-6183
EmailpermitsR8MB@fws.gov