Form 3-2541 6(a)(2) Adverse Incident Report

FWS Form 3-2541 (Rev. 05/2021) OMB Control No. 1018-####

U.S. Fish and Wildlife Service Expires ##/##/####

6(a)(2) ADVERSE INCIDENT REPORT

Carbon Dioxide – Carp Program Management

Applicator must provide all known, required information within 15 calendar days of the incident. If required information is unknown, designate as “unknown” in appropriate area.

Section I. Administrative Data

Reporter name:	Contact Person (if different than reporter):	Submission Date:
Address:	Address:	Incident Status (if update, include date of original submission): New      Update	Location and date of Incident (City, County, State)
Phone Number:	Phone Number:	Date Registrant became aware of incident:	Was incident part of a larger study? Y____ N ____ U ____

Section II. Pesticide Involved

EPA Registration No.: 6704-95

A.I. Carbon dioxide

Product Name: Carbon Dioxide-Carp

Exposed to concentrate prior to dilution?

Y       N     U       NA      

Formulation Type: gas

Section III. Incident Circumstances

Evidence label directions were not followed. Y____ N ____ U ____ Intentional misuse____	Incident site (e.g. stream, river, roadway):	Situation (act of using product, for example mixing/loading, reentry, application, transportation, repair maintenance of application equipment, manufacturing/formulation):
Applicator certified Pest Control Operator? Y____ N ____ U ____
How exposed (examples include direct contact with treated surface, ingestion, spill, drift, runoff):	Brief description of incident circumstances:

Section IV. Information Involving Fish, Wildlife, Plants or Other Nontarget Organisms.

List species affected and number of individuals per species:
List symptoms or adverse effects:
Magnitude of the effect (examples: miles of stream, square area of terrestrial habitat):	Pesticide application rate, intended use site (examples: corn, turf) and application method:
If plant, plant type (examples: crop, forest, forage, orchard, home garden, ornamental):
If lab test(s) performed, list name of tests and results (submit laboratory report(s) if available):
Description of the habitat and the circumstances under which the incident occurred:
Distance from treatment site:	Fish, wildlife, plant, other non-target organism severity categories (include all categories that apply; e.g. W, P, ONT):_____:   __    :    __   W=wildlife, P= plant, ONT = other non-target
This box can be used to provide any explanatory or qualifying information surrounding the incident (add additional pages if necessary):

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 Marine Mammal Protection Act (16 U.S.C. 1361, et seq.), 50 CFR 18; 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. This helps FWS monitor and report on protected species and assess 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

We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to provide the U.S. Fish and Wildlife Service the information necessary, under the applicable laws governing the requested activity, for which a permit is requested. 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 applicable 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-####.

ESTIMATED BURDEN STATEMENT

We estimate public reporting for this collection of information to average 50 minutes for electronic submissions and 60 minutes for hard copy submissions, 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: 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.

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