VS 4-33 Brucellosis Test Record

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