Form VS 1-36A VS 1-36A APPLICATION FOR VETERINARY ACCREDITATION

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not 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 0579-0032. The time required to complete this information collection is estimated to average .5 hours 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.							OMB APPROVED 0579-0032
No accreditation may be granted unless a completed application form has been received (9 CFR Part 161).
U.S. DEPARTMENT OF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECTION SERVICE VETERINARY SERVICES APPLICATION FOR VETERINARY ACCREDITATION
1. NAME OF VETERINARIAN (First, Last, Middle Initial)		2. LAST 4 DIGITS OF SOCIAL SECURITY NUMBER		3. BIRTHDAY (mm/dd/yyyy)
4. NAME OF COLLEGE (Graduated)		5. YEAR GRADUATED		6. DATE OF ORIENTATION (mm/dd/yyyy)
7. STATE OF ORIENTATION		8. HOME MAILING ADDRESS
9. COUNTY		10. HOME TELEPHONE NUMBER		11. HOME FAX NUMBER
12. BUSINESS NAME
13. BUSINESS ADDRESS
14. COUNTY	15. BUSINESS TELEPHONE NUMBER		16. BUSINESS FAX NUMBER			17. CELL NUMBER
18. EMAIL ADDRESS			19. EMPLOYER TYPE (i.e., Private, State)
20. PROFESSIONAL ACTIVITY (i.e., small animal, large animal, etc.)			21. SPECIES SPECIALTY (if applicable)(i.e., swine, bovine)
22. STATE APPLYING FOR ACCREDITATION			23. STATE LICENSE NUMBER
24. Do you want your name and business information released for a public search of accredited veterinarians? yes no
TASKS FOR ACCREDITED VETERINARIANS Perform physical examinations of individual animals and visually inspect herds or flocks. Recognize the common breeds of livestock. Recognize brucellosis tattoos and calfhood vaccination tags, and determine the State of origin of eartags. Estimate the age of livestock using a dental formula. Apply an eartag, tattoo, backtag, and legband. Certify the disease status of a flock for shipment of birds. Properly complete certificates for domestic and international movement of animals. Apply and remove official seals. Perform a necropsy on livestock. Recognize signs and lesions of exotic animal diseases. Plan a disease control strategy for a livestock unit. Vaccinate for brucellosis and fill out the vaccination certificate. Draw and ship blood for testing. Perform a caudal fold test for tuberculosis. Develop cleaning and disinfection plans to control communicable livestock disease spread. Explain basic principles for control of diseases for which APHIS or APHIS-State cooperative programs exist, such as brucellosis, pseudorabies, and tuberculosis.
CERTIFICATION I certify that I am able to perform the tasks listed above and have been given a copy of the Standards for Accredited Veterinarian Duties. I agree to conduct all activities as an accredited veterinarian in accordance with the Accredited Veterinarian Duties contained in Title 9, Code of Federal Regulations, Subchapter J, Part 161.3, and any amendments there to which may subsequently be issued and in accordance with instructions received from the Veterinarian-in-Charge.
25. SIGNATURE OF VETERINARIAN					26. DATE
Signature of the Veterinarian-in-Charge and the State Animal Health Official appearing below denote endorsement of the applicant for veterinary accreditation.
27. SIGNATURE OF VETERINARIAN-IN-CHARGE					28. DATE
29. SIGNATURE OF STATE ANIMAL HEALTH OFFICIAL					30. DATE
(Previous editions are obsolete) VS FORM 1-36A MAY 2009

PRIVACY ACT NOTICE

General:

This information is provided pursuant to Public Law 95-3579 (Privacy Act of 1974) December 31, 1974, for individuals completing the VS 1-36A.

Authority:

U.S. Code, Title 5, Section 3301 – this is what is on the current VS 1-36A 7 U.S.C. and 8309, 21 U.S.C. 113a – this is what is on the new SOR.

Purpose and Use:

The purpose of this form is to apply for veterinary accreditation by the Animal and Plant Health Inspection Service, U.S. Department of Agriculture.

Routine Uses:

This information will be used for (1) Referral to State Animal Health officials to certify accreditation status, (2) Referral to State veterinary examining boards to certify accreditation status. (3) Referral to the appropriate agency, whether Federal, State, local, or foreign, charged with the responsibility of investigating or prosecuting a violation of law; or of enforcing or implementing the statute, rule, regulation, or order issued pursuant thereto, of any record within this system when information available indicates a violation or potential violation of law, whether civil, criminal, or regulatory in nature; and whether arising by general statute or particular program statute, or by rule, regulation, or order issued pursuant thereto. (4) Disclosure to the Department of Justice has agreed to represent the employee, or the United States, where the agency determined that litigation is likely to affect the agency or any of its components, is a party to litigation or has an interest in such litigation, and the use of such records by the Department of Justice is deemed by the agency to be relevant and necessary to the litigation, provided, however, that in each case, the agency determines that disclosure of the records to the Department of Justice is a use of the information contained in the records that is compatible with the purpose for which the records were collected.

(5) Disclosure in a proceeding before a court or adjudicative body before which the agency is authorized to appear, when the agency, or any component thereof, or any employee of the agency in his or her official capacity, or any employee of the agency in his or her individual capacity where the agency has agreed to represent the employee, or the United States, where the agency determines that litigation is likely to affect the agency or any of its components, is a party to litigation or has an interest in such litigation, and the agency determines that use of such records is relevant and necessary to the litigation; provided, however, that in each case, the agency determines that disclosure of the records to the court is a use of the information contained in the records that is compatible with the purpose for which the records were collected. (6) Disclosure may be made to a congressional office from the record of an individual in response to an inquiry from the congressional office made in the request of that individual. (7) To periodically disseminate information and solicit feedback from accredited veterinarians within the system on proposed Federal programs for the purpose of educating and involving the accredited veterinarians in current program development, program requirements, and standards of conduct. (8) Disclosure to the public for the purpose of locating and contacting accredited veterinarians for a specific geographical location. (9) To contact accredited veterinarians to solicit participation in emergency response efforts to contain or control animal diseases of regulatory concern.

Effects of Nondisclosure:

Although this information is voluntary, failure to complete all the information may delay the process of the application or it may result in the application not being processed. The social security number and birth date will be used to create a unique identifier.