VS 4-33 Brucellosis Test Record

Brucellosis Program

4-33

Brucellosis Program - State

OMB: 0579-0047

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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 number. The OMB control number for this information collection is 0579-0047. The time required to complete this collection of information is estimated to average .17 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

0579-0047

Exp. XX/XXXX

STATE


ALL INCOMPLETE RECORDS WILL BE RETURNED FOR COMPLETION


COOPERATIVE STATE-FEDERAL BRUCELLOSIS ERADICATION PROGRAM

BRUCELLOSIS TEST RECORD

COUNTY

CODE


HERD NUMBER

HERD OWNER LAST FIRST INITIAL


PREVIOUS

TEST DATE

VET CODE

TOTAL

REA

SUS




PREMISES ID NO.

ROUTE STREET ROAD


CERTIFICATION F0R PAYMENT

FEDERAL EMPLOYEE

FEE BASIS

(Federal)

STATE

COUNTY

PRIVATE

(owner’s

expense)


POST OFFICE STATE ZIP CODE



I CERTIFY:

That I have drawn blood samples from each animal identified below and have correctly listed each tube number with 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.

REASON FOR TEST INITIAL RETEST

GPS COORDINATES


Slaughter 1

Rea


Hd. Cert/ 6 Validation


COMPLETE HERD TEST OF ALL ELIGIBLE ANIMALS


YES NO

NO. IN HERD

STATE

Lvst. Mkt. 2

Rea


Post Move 7

Quar. Test


NEG-

ATIVE


Susp. Ring 3

Test


8

Area Test



SUS-

PECT


SIGNATURE

AGREE CODE

4

Diagnostic



9

Epidemiology




KIND OF HERD


DAIRY BEEF MIXED

SWINE OTHER (Specify

below)

ROUTE-STREET-ROAD

DATE BLED

REAC-TOR


5

Pvt. Sate



Other 10

(Specify below)


POST OFFICE STATE ZIP CODE

FIELD TEST DONE BY:

REMARKS

laboratory


TOTAL


PLACE

DATE


REACTORS TAGGED AND BRANDED

DATE: SIGNATURE:


AGREE CODE

DATE LISTED


BY:

LABORATORY RESULTS

TEST IN -TERP

REMARKS


AND

ADDITIONAL

INFORMATION

REACTOR

TAG NUMBER




TUBE NO.

2

RECORD ALL

IDENTIFICATION

NUMBERS(S)

VACC

TATTOO

AGE

BREED

SEX

FLD

T

RAP

FPA

CARD

BAPA

CF




1

















2

















3

















4

















5

















6

















7

















8

















9

















10

















11

















12

















13

















14

















15
















RT – Retag

NA – Natural Addition

PA – Purchased Addition

AB – Aborter


Record ALL Eartag(s) and Tattoo(s)


Record ALL Legible Characters

FIELD TEST CODE


N – Negative

P – Positive

TEST INTERPRETATION

N – Negative Classified by:

S – Suspect___________________________

R – Reactor date Classified:

TEST AUTHORIZATION EXPIRES








VS FORM 4-33

APR 2009

File Typeapplication/msword
File TitleAccording to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it di
AuthorGovernment User
Last Modified ByKhbrown
File Modified2009-04-15
File Created2009-04-15

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