VS 4-106 Field Investigation of Brucellosis Market Test Reactors

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 .50 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

USDA – aPHIS field investigation of brucellosis market test reaCtor(s)

1. MCT LOG (vs Form 4-100)

2. date investigation started

Book No.

Page No.

3. date bled

4. place bled Mkt. Slau.

name and address of market or slaughter est.

5. name of testing lab.

state

6. backtagged

7. no. backtagged

Date

location

date

REACTOR ANIMAL(S)

(a) back tag no.

(b) ear tag no.

(c) sales tag no.

(d) other identification

(e) plate test

(f) card test

(g) OPTIONAL TESTS

8.

9.

10.

(h) SPECIES

(i) BREED

(J) COLOR

(K) SEX

(L) AGE

(M) VAC. STATUS

(N) SCALE WT. (lb.)

(O) LIVE WT. (lb.)

8.

9.

10.

TRACING TO ORIGIN

11. NAME AND ADDRESS OF CP CONSIGNOR

(a) cOUNTY

(b) NO. ANIMALS MOVED WITH REACTOR

12. NAME AND ADDRESS OF OWNER (If different from consignor)

herd information

13. date of last herd infection None

14. date of last mct reactor None

15. date of last positive brt None

16. percent of herd vaccinated for bruc. %

17. clinical signs of bruc. in herd Yes No Unknown

18. time reactor in herd

19. type of herd Dairy Beef Both

20. cattle census on premises

a. cows

b. bulls

c. steers

d. calves under 12 mo.

e. heifers 1-2 years

(1) Vac.

(2) nv

(1) Vac.

(2) nv

21. herd scheduled for test

22. has herd been quarantined Yes No

Date (If “Yes”)

Date

By

NO (If “No” explain fully in item 24.)

tracking exposed animals

23. animals from this consigment sold

(a) no. animals

(b) name and address of buyer

sold for

(e) identification no. (Back tag, Sale tag, etc.)

(c) slau.

(d) return to farm

24. remarks (Attach a separate sheet.)

25. investigator (Signature)

26. title

27. date

VS FORM 4-106

APR 2009

Form Copy Designations

Part 1

Part 2

Part 3

Part 4