Sea Lamprey Control Landowner Questionnaire

SEA LAMPREY CONTROL LANDOWNER QUESTIONNAIRE

«Name_Prefix» «First_Name» «Last_Name» «Name_Suffix»

«Organization»

«Address1»

«Address2»

«City», «State» «Zip_Code»

1. I own/lease/manage property on the «Stream_Name» system. Please provide property address if different than mailing address.

2. Access Permissions. Please select and sign.

­­­___ The USFWS has permission to use my property, please call before accessing property.

___ The USFWS has permission to use my property, no further contact is needed.

___ The USFWS is DENIED permission to use my property. Please explain why on the back of this form.

___ The USFWS has standing permission to use my property for future sea lamprey control work.

Standing permission is defined as being able to access ones property whenever needed for Sea Lamprey Control purposes without prior contact.

Signature: ______________________________ Date: _________________

3. I can be contacted at: Preferred form of Contact

Phone 1:____________________ Home Cell Office Phone

Phone 2:____________________ Home Cell Office Email

Email: ____________________________________

When is the best time to Contact: Morning / Evening Weekday / Weekend

4. Do you have an alternate contact person? Yes No

If yes: Name: ________________________________

Contact #: _____________________________

5. I use stream water for irrigation purposes? Yes No Other Uses of Stream Water (Please Explain)

6. What type of transportation is allowed on your property? Please check all that apply.

Foot Truck ATV

7. Is a gate key or gate combination needed to access a road or trail? Yes No

8. Please use this space below for any questions you may have about the upcoming treatment or about sea lamprey management. Please continue on back if needed.

______________________________________________________________________________

Office Use Only: «Lake»/«Stream»/«REFIDS»

Paperwork Reduction Act Statement: In accordance with the Paperwork Reduction Act (44 U.S.C. 3501 et seq.), the U.S. Fish and Wildlife Service collects this information which is critical to the delivery and evaluation of an integrated control program to manage invasive sea lamprey populations in the five Great Lakes. Your response is voluntary and we will not share your response publicly. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a currently valid OMB Control Number. OMB has reviewed and approved this focus group and assigned OMB Control Number 1018-####.

Estimated Burden Statement: We estimate it will take 5 minutes to respond, including time to read instructions and gather information. You may submit comments on any aspect of this information collection to the Service Information Collection Clearance Officer, U.S. Fish and Wildlife Service, 5275 Leesburg Pike, MS: PRB (JAO/3W), Falls Church, VA 22041-3803, or via email at Info_Coll@fws.gov. Please do not send your completed form to this address.