Form VS-4-33 Brucellosis Test Record

According to the Paperwork Reduction Act of 1995, no persons are required to re spond to a collection of information unless it displays a valid OMB control num ber. The valid OMB
control number for this information collection is 0579-0032. The time required to complete this collection of information is estimated to average .16 hours p er response, including
the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the form.
STATE

ALL INCOMPLETE RECORDS WILL BE RETURNED FOR COMPLETION

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES

COUNTY

CODE

HERD NUMBER

HERD OWNER

OWNER NUMBER

ROUTE-STREET-ROAD

LAST

COOPERATIVE STATE-FEDERAL BRUCELLOSIS ERADICATION PROGRAM

BRUCELLOSIS TEST RECORD

FIRST

PREVIOUS
TEST DATE

MIDDLE INITIAL

WET CODE

PROG.

WBBS POST OFFICE

REASON FOR TEST
Slaughter
Rea

1.

Lvsl. Mkt.
Rea

2.

Susp Ring
Test

3.

Diagnostic

4.

Pvt. Sale

5.

STATE

INITIAL

RETEST

Hd. Cert/
Validation

6.

Post Move
Quar. & Test

7.

Area Test

8.

Epidemiology

Other
(Specify below)

RGE

TWP

ZIP CODE

SEC

DISTRICT

YES

NO. IN HERD

9.

DAIRY
SWINE

10.

KING OF HERD
BEEF

FARM UNIT

NEG
ATIVE

NO

SUSPECT

MIXED

FEE BASIS
(fEDERAL)

That I have drawn blood samples from each animal identified below
and have correctly listed each tube number with complete
corresponding identification number, all numbers and letters of all
eartags have been listed, cattle with existing official eartags have not
been retagged, and when payment is claimed at program expense in
accordance with agreement number below, no payment has been or
will be received from any other source.
SIGNATURE

AGREE. CODE

ROUTE, STREET, ROAD

DATE BLED

REACTOR

POST OFFICE

DATE

TOTAL

REACTORS TAGGED AND BRAND
DATE
SIGNATURE

BY
RECORD ALL
IDENTIFICATION
NUMBER (S)

PRIVATE
(Owner's Expense)

OTHER (Specify below)

PLACE

2

SUS

STATE
COUNTY

STATE

ZIP CODE

LABORATORY

DATE LISTED

REA

I Certify

SUMMARY

COMPLETE HERD TEST OF
ALL ELIGIBLE ANIMALS

REMARKS:

TUBE
NO.

TOTAL

CERTIFICATION FOR PAYMENT
FEDERAL
EMPLOYEE

TEST

FORM APPROVED OMB NO.
0579-0032 and 0579-0185

AGREE. CODE

LABORATORY RESULTS
SEX
VACC
TATTOO

AGE

BREED

FL
DT

BAPA
RST

CARD

STT

RIV

CF

SPT

FIELD TEST DONE
BY

REMARKS
TEST
in
terp

AND
ADDITIONAL
INFORMATION

REACTOR
TAG
NUMBER

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

RT - Retag
AB - Aborter
NA - Natural Addition
PA - Purchased Addition

VS FORM 4-33
(SEP 2005)

Record ALL
Eartag(s) and
Tattoo(s)

Record ALL
Legible
Characters

FIELD TEST
CODE
N - Negatuve
P - Positive

TEST INTERRPRETATION
N - Negative Classified by:
S - Suspect
R - Reactor Date Classified

Record ALL
Eartag(s) and
Tattoo(s)