VS 5-19 Flock Inspection and Epidemiology Report

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 0579-0101. The time required to complete this information collection is estimated to average 1 hour per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information.
1. SFCP PARTICIPANT

U.S. DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES

Yes

FLOCK INSPECTION AND EPIDEMIOLOGY REPORT

Applicant

4. FLOCK LOCATION (If different from Item 3.)

Telephone Number

GPS NO.

(

)

9. FLOCK TOWNSHIP

10. RANGE

2. INSPECTION DATE
No

3. OWNER NAME/CONTACT, ADDRESS AND TELEPHONE NO. (Include Zip Code)

5. INSPECTOR'S/VMO'S NAME

FORM APPROVED
OMB NO. 0579-0101

6. INSPECTOR'S ID

7. FLOCK ID

8. FLOCK COUNTY

11. SECTION

12. LATITUDE

13. LONGITUDE

14. REASON FOR INSPECTION (Please check all that apply)
Routine

High Risk Animals

Exposed Animals

15. FLOCK STATUS (Please check all that apply)
Certified

Enrolled

Select

Other (Please Specify)

Clinically Suspicious

Source

Exposed

Plan

Invest

Infected

Other (Please Specify)

P Plan

16. FLOCK TYPE (Please check one box)
Purebred

Commercial Breeder

Feeder

Other (Please Specify)

17. FLOCK INVENTORY
Males > 1 Yr.

Males < 1 Yr.

Castrated Males < 1 Yr.

Females > 1 Yr.

Females < 1 Yr.

Other (Please Specify)

18. VETERINARY PRACTITIONER'S NAME

Total

19. PRACTITIONER'S ID

21. PREDOMINANT BREED(S)

20. SPECIES
Ovine

Caprine

22. FLOCK HISTORY AND REMARKS (Attach additional sheets, if needed.)

23. FLOCK IDENTIFIED THROUGH ANIMAL MOVEMENT (List name, location, reason, and known dates for each. Attach additional shee ts, if needed. For each positive and exposed animal which has
moved from the flock, complete and attach VS Form 5-20.)
Name

Address

City

State

Reason (Circle One)

Zip Code

A.

Date

Origin of Positive
Disposition, High Risk
Disposition, Exposed

B.

Origin of Positive
Disposition, High Risk
Disposition, Exposed

C.

Origin of Positive
Disposition, High Risk
Disposition, Exposed

D.

Origin of Positive
Disposition, High Risk
Disposition, Exposed

E.

Origin of Positive
Disposition, High Risk
Disposition, Exposed

24. FLOCK OWNER'S SIGNATURE

25. HAVE YOUR EWES HAD DIRECT CONTACT (fence to fence or direct
mixing) WITH NO PROGRAM SHEEP OR SHEEP WITH A
LATER STATUS DATE SINCE LAST INSPECTION (SEE REMARKS)
Yes

27. INSPECTOR'S/VMO' S SIGNATURE

No

N/A

STATUS DATE OF EWES ONLY (if checked yes)

26. HAVE ANY OF YOUR SHEEP BEEN ON
PREMISES OR PASTURES NOT LISTED ON
PREVIOUS REPORTS
Yes

No

N/A

30. SFCP STANDARDS
Meeting Standards

28. CONDITION OF ANIMALS
All Clinically Normal
Clinically Suspicious Animals Seen
VS FORM 5-19 JUL 2004

29. HAVE RAMS OF LOWER PROGRAM STATUS BEEN INTRODUCED INTO
THE FLOCK
YES
NO
N/ A
STATUS DATE OF RAMS ONLY (if checked yes)
(Previous editions are obsolete.)

Not Meeting Standards (explain in #22 )
Not Applicable