VS 4-24 Calfhood Vaccination Record - Short Form

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 0579-0047. The time required to complete this information collection is estimated to average .083 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

STATE

ALL VACCINATIONS MUST BE PROMPTLY REPORTED COOPERATIVE STATE-FEDERAL BRUCELLOSIS ERADICATION PROGRAM BRUCELLOSIS VACCINATION RECORD

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

COUNTY

CODE

HERD NUMBER

HERD OWNER LAST FIRST INITIAL

VACCINE USED

EXPIRATION DATE

OWNER NUMBER

ROUTE-STREET-ROAD

SERIAL NUMBER

DOSAGE FULL REDUCED

VACC. TATTOO

KIND OF HERD DAIRY BEEF MIXED

POST OFFICE STATE ZIP CODE

CERTIFICATION FOR PAYMENT

FEDERAL EMPLOYEE

FEE BASIS (Federal)

STATE COUNTY

PRIVATE (Owner’s Expense)

REMARKS

WBBS

CV AV

RGE

TWP

SEC

DISTRICT

FARM UNIT

I CERTIFY THAT: (1) I have vaccinated with Strain 19, tattooed and eartagged or otherwise properly identified all

NO.

IDENTIFICATION NUMBER

AGE (MO/YR.)

BREED

SEX

P/B- GRADE

* TATTOO

animals listed hereon as prescribed by the Brucellosis UM and R, and recorded all information as prescribed by State regulations; (2) 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.

1.

2.

Signature

Date of Vacc-ination

Agree. Code

3.

CERTIFICATION OF OWNER OR WITNESS I CERTIFY THAT the animals listed hereon were vaccinated and identified for the above named owner.

4.

5.

Signature

Date

6.

CERTIFICATION FOR RE-ESTABLISHING VACCINATION STATUS * indicate tattoo of animals previously vaccinated in appropriate column. I CERTIFY THAT I have personally examined the animal(s) noted hereon, and have read the official tattoo(s) and have retagged them as shown.

7.

Signature

Date

8.

VS FORM 4-24 Previous edition may be used

MAR 2009

Copy designationS

Part 1 – Office

Part 2 – office

Part 3 – owner

Part 4 – Veterinarian