Veterinarian Shortage Situation Nomination Form

	NIFA Veterinary Medicine Loan Repayment Program (VMLRP)		National Institute of Food and Agriculture US Department of Agriculture OMB Information Collection Approval No.: 0524-XXXX
Veterinarian Shortage Situation Nomination Form
		To be completed by the State or Insular Area Animal Health Official
Veterinary Medicine Loan Repayment Program (VMLRP)

Nomination of Veterinarian Shortage Situations for the Veterinary Medicine Loan Repayment Program (VMLRP) Authorized Under the National Veterinary Medical Service Act (NVMSA)

Note: Please submit one separate nomination form for each position. See solicitation for number of nominations permitted for your state or insular area.

Location of Veterinary Shortage Area for this Nomination

Note: If this nomination is for a public practice position, please provide the location of the home office or the center of service area.

Location of Veterinary Shortage:
	(e.g., County, State/Insular Area)
Center of Service Area or Location of Position:
	(e.g., Address or Cross Street, Town/City, and Zip Code)

Type of Veterinary Practice Area/Discipline/Specialty

	Type I Shortage: Private Practice
		Food Animal Medicine (at least 80 percent time)
			Please select one or more specialties requested for this position:
					Beef Cattle
					Dairy Cattle
					Swine
					Poultry
					Small Ruminant
					Other ________________________________

	Type II Shortage: Private Practice – Rural Area
		Food Animal Medicine (at least 30 percent time)
			Please select one or more specialties requested for this position:
					Beef Cattle
					Dairy Cattle
					Swine
					Poultry
					Small Ruminant
					Other : _______________________________

Type III Shortage: Public Practice (at least 49 percent time*)

Employer:

Position Title:_______________

Please select one or more specialty/disciplinary areas.

Food Safety

Public Health

Epidemiology

Other:

Please describe the objectives of a veterinarian meeting this shortage situation as well as being located in the community, area, state/insular area, or position requested above (limit your response to 200 words or less).

Please describe the activities of a veterinarian meeting this shortage situation and being located in the community, area, state/insular area, or position requested above (limit your response to 200 words or less).

Please describe any past efforts to recruit and retain a veterinarian in the shortage situation identified above (limit your response to 100 words or less).

Please describe the risk of this veterinarian position not being secured or retained. Include the risk(s) to the production of a safe and wholesome food supply and to animal, human, and environmental health not only in the community but in the region, state/insular area, nation, and/or international community (limit your response to 250 words or less).

Please indicate whether you consider this situation/position a candidate for a “service in emergency” agreement (limit your response to 100 words or less). Please see solicitations for additional information regarding the obligation of participants who enter into the “Service in Emergency” agreement.

Authorized State or Insular Area Animal Health Official or designee:

Name:
Title:
Organization:
Email:
Telephone Number:
	(Area code required)
Signature				Date

Public reporting for OMB control number 0524-XXXX is estimated to average two hours, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless it displays a current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to NIFA, OEP, 800 9^th St. SW, Washington, DC 20024, Attention Policy Section. Do not return the completed form to this address.

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