Form VS 9-2 VS 9-2 FLOCK SELECTING AND TESTING REPORT

FORM APPROVED OMB NO. 0579-0007

REPORT NO.

See reverse side for additional information.

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
NATIONAL POULTRY IMPROVEMENT PLAN

FLOCK SELECTING AND
TESTING REPORT

SUBPART:

L

CLASSIFICATION - U.S.

B - Egg Type Chickens
C - Meat Type Chickens
D - Turkeys
E - Waterfowl, Exhibition
Poultry and Game Birds
F - Ostrich
Other

Salmonella enteritidis Clean

Pullorum - Typhoid Clean

Salmomella Monitored

M. Gallisepticum Clean

M.G. Monitored

TYPE
Primary

M.S. Monitored

M. Synoviae Clean

Multiplier

Avian Influenza Clean

Sanitation Monitored

H5/H7 Avian Influenza Monitored

M. meleagridis Clean

Other

1. Name and Address of Flockowner (Include Zip Code)
2. Location of Flock

3. Date of Preceding Test - This Location

4. Supply Flock for: (Name and address of hatchery or dealer - include Zip Code)

Approval Number

5. Breed, Variety, Strain or Trade Name of Stock
6. Males (Source and Number)

Blood Testing

Date of Hatch

a. Number of Males
Tested

b. Number of
Females Tested

7. Females (Source and Number)
c. TOTAL Number
Tested

d. Number of
Reactors

Age of Birds

Code Identification

Date of Hatch

8. Total Birds in Flock

e. Number Sent to
Laboratory

f. Laboratory Findings

9. PULLORUM TYPHOID
10. M. GALLISEPTICUM
11. M. SYNOVIAE
12. OTHER (specify)
AGREEMENT OF FLOCKOWNER

Signature of Inspector or authorized agent

I agree to keep my poultry breeding stock segregated from other poultry and in
accordance with the provisions of the Plan and regulations of the Official State
Agency. I further agree to flock inspection by a representative of the Official State Signature of Flockowner
Agency as prescribed by the provisions and regulations.
VS FORM 9-2 (JUL 2005)

Previous edition may be used.

Date

Date

This report is required by regulation (9 CFR 145). Failure to report can result in
non-classification of poultry and poultry products under the NPIP.

FORM APPROVED
OMB NO. 0579-0007

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
NATIONAL POULTRY IMPROVEMENT PLAN

FLOCK SELECTING AND TESTING REPORT

REPORT NOS. FROM

VS FORM 9-2 (JULY 2005) Previous edition may be used.

TO

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection
of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0579-0007 The time required to complete this information collection is
estimated to average .116 hours per response, including the time to review instructions, search existing
data resources, gather the data needed, and complete and review the information collection.

COPY DESIGNATIONS
LOWER RIGHT CORNER
RED INK

PART 1 - OFFICIAL STATE AGENCY COPY

PART 2 - AGENT OR LABORATORY COPY

COPY 3 - HATCHERY/SLAUGHTER PLAN/EGG PRODUCERS' COPY

COPY 4 - FLOCK OWNER/GROWER'S COPY