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 mjones@indremcs.org 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
If recovered, circle one of the following:
by USFWS
Veterinarian
Not Recovered
Disposed of
Rehab Center
Transferred-to/Picked-up-
Enter disposition details (i.e., how disposed of, name of rehab center, name of USFWS employee, name
of vet: Click here to enter text.
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Apparent cause of fatality/injury: Electrocution
Probable Electrocution
Collision
Other (explain) Click here to enter text.
Was this incident associated with a power outage?
Yes
Collision
Probable
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):
Weather Conditions (mark all that apply):
Forest
Clear
Fog
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Grassland
Wind
Rural
Snowing
Wetland
Raining
Urban
Food sources nearby (mark all that apply): River or Creek
Lake or Pond
Landfill
Prey
Bird Feeder Other food source – please specify: Click here to enter text.
Dumpster
Details about nesting information (i.e., is there a nest on utility structure or in the area?):
If yes, describe location. Click here to enter text.
Yes
No
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?:
If so, how many?:
1-5
Yes
6-10
No
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
mjones@indremcs.org
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
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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, 317-6966246 or your regional Regulatory Compliance Consultant. Thank you for your cooperation in
maintaining compliance with our USFWS Special Purposes Permit.
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