Indiana Statewide/U.S. Fish and Wildlife Service

Bird Fatality/Injury Reporting Program

Field Report

Point of Contact Information

Name of Individual Filing Report: Click here to enter text.

Name of Company/Organization: Click here to enter text.

Mailing Address: Click here to enter text.

Phone Number: Click here to enter text.

Email: Click here to enter text.

Fatality/Injury Details

Date the Bird was Discovered: Click here to enter

Time Bird was Discovered and by whom: Click here to enter text.

Type of Bird: Click here to enter text.

(Note: if bird species is unknown, photograph the bird and email to You can also text a photo of bird to Marty Jones, 317-696-6246. A photo with a mobile phone is sufficient. You will receive a reply as to identity of bird species)

Condition of Bird (check one): Alive Dead

Describe any visible injuries to the bird: Click here to enter text.

If alive, actions taken: Click here to enter text.

Describe any visible injuries to the bird: Click here to enter text.

Disposition of the bird: Recovered Not Recovered

If recovered, circle one of the following: Disposed of Rehab Center Transferred-to/Picked-up-by USFWS Veterinarian

Enter disposition details (i.e., how disposed of, name of rehab center, name of USFWS employee, name of vet: Click here to enter text.

Apparent cause of fatality/injury: Electrocution Probable Electrocution Collision Probable Collision Other (explain) Click here to enter text.

Was this incident associated with a power outage? Yes No

If incident was associated with an outage, indicate length of time power was out: Click here to enter text.

Location Where Bird Was Found

State: INDIANA

County, nearest Town or Community and Road: Click here to enter text.

Circuit Number/Circuit Name: Click here to enter text.

Pole Number (if applicable): Click here to enter text.

GPS Coordinates (if available): Click here to enter text.

Configuration Details

Enter the name of the configuration type that most closely matches the one involved in this incident (e.g., Single-phase Crossarm (RUS A9-1), Substation, etc.): Click here to enter text.

If you entered “Substation”, identify all applicable equipment: Click here to enter text.

If this incident was related to an electrocution, or possible electrocution, enter all applicable equipment on the pole (e.g., arrestors, capacitors, cutout, switches, brackets, etc.): Click here to enter text.

Enter the voltage, in Kv: Click here to enter text.

Did ground wire, or neutral, contribute to the electrocution?:Yes No

If there was a cross-arm, what was the length?:Click here to enter text.

If pole or equipment on pole is suspected cause, where was bird found in relation to pole or equipment?: Click here to enter text.

Environmental Conditions

Surrounding Environment (mark all that apply): Forest Grassland Rural Wetland Urban

Weather Conditions (mark all that apply): Clear Fog Wind Snowing Raining

Food sources nearby (mark all that apply): River or Creek Lake or Pond Landfill Dumpster Prey Bird Feeder Other food source – please specify: Click here to enter text.

Details about nesting information (i.e., is there a nest on utility structure or in the area?): Yes No If yes, describe location. Click here to enter text.

Existing Utility Avian Protection/Retrofit Measures

At the time of the bird fatality/injury, did utility avian protection exist at contact location?: Yes No If yes, please mark all existing raptor protection devices that apply: Bird deterrent device (other than perch guard), please describe: Click here to enter text. Bird Flapper device (i.e. “Firefly”) Bird or Swan Flight Diverter Bushing Cover(s) Conductor Spacing increased, please describe: Click here to enter text. Elevated Perch Extension Link (non-conducting) Groundwire Cover/Insulation Jumper Wire Cover/Insulation Jumper Wire(s) Suspended under crossarm

Lowered Crossarm Perch Guard(s) (to discourage bird from perching) Pole-top extension Primary Insulator Cover (i.e. “Birdguard”) Other raptor protection, please describe: Click here to enter text.

Additional Information/Photographs

It is important to describe avian-safe corrective actions you have made following the discovery of the bird. Research indicates avian fatalities routinely occur repeatedly at the same location. Preventing bird-caused outages is not just a conservation concern, it is also an economic and public relations concern for utilities which in many cases is preventable. Please include additional observations including avian-safe corrective actions in place or to be installed. If avian-safe corrective measures are planned, be sure to provide date corrections are expected to be completed:Click here to enter text.

Did you take photographs?: Yes No

If so, how many?:1-5 6-10 more than 10

Along with this report, please include photographs which show key features of utility equipment involved with the bird fatality/injury. Also, include photo’s of the bird, if available.

Submit completed report and photo’s via snail mail or email to:

Marty Jones

Regulatory Compliance Program

Indiana Statewide Association of Rural Electric Cooperatives

720 North High School Road

Indianapolis, Indiana 46224

317-696-6246

Upon receipt of this completed form, Indiana Statewide will process your information into the USFWS database. Indiana Statewide will also include your information into the required annual report and correspond with USFWS on questions concerning this issue. Furthermore, you will be copied on a USFWS confirmation report number once your data from this form has been entered into the USFWS database. Statewide recommends you save/file a copy of this report and the confirmation number. Should you have questions during any point of the reporting process, please call Marty Jones, 317-696-6246 or your regional Regulatory Compliance Consultant. Thank you for your cooperation in maintaining compliance with our USFWS Special Purposes Permit.

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