vs 17-65A Zoological Park Inspection Report

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to re spond to, a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0579-00 40. The time required to
FORM APPROVED
complete this information collection is estimated to average 5 hours per response, including the time for reviewing instructions, se arching existing data sources, OMB NO. 0579-0040
gathering and maintaining the data needed, and completing and reviewing the collection of information.
This report is required by law (9 CFR 93). Failure to complete this form with result in zoo animals not being released from quarantine.
1. NAME AND MAILING ADDRESS OF ZOO

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

ZOOLOGICAL PARK INSPECTION REPORT
2. NAME OF ZOO DIRECTOR

3. ADMINISTRATION
FEDERAL

4. ZOO VETERINARIAN (Name and Address)

MUNICIPAL
5. RESPONSIBLE OFFICIAL (Name and Address)

COUNTY

STATE

PRIVATE

PHONE

6. VETERINARY SERVICE ("X" one)
FULL TIME

7. LOCATION CITY OR TOWNSHIP
OF ZOO

PART

8. TOTAL ACREAGE IN 9. APPROX. ZOO ACREAGE
ZOO
USED FOR RESTRICTED
RUMINANTS AND SWINE

10. NO. RESTRICTED
ANIMALS ON ZOO
PROPERTY NOW

13. Is zoo completely enclosed by a fence that is an adequate livestock
barrier?

CHECK
YES

NO

PART TIME

ON CALL

COUNTY

11. NO. OTHER RUMINANTS OR SWINE
HELD WITH RESTRICTED
ANIMALS NOW

12. APPROX. TOTAL ANIMALS ON ZOO
PROPERTY NOW
RUMINANTS

SWINE

EQUINE

IF "NO" FOR ANY ITEM, COMMENT REQUIRED
(Attach additional sheet, if necessary)

14. Are restricted animal exhibits isolated from contact with the public?
15. Are restricted animal exhibits isolated from domestic livestock?
16. Are post mortem examinations performed on all restreicted animals?
(if "yes" check)
on zoo grounds

Other

17. Are post mortem examinations performed on all other animals?
(If "yes" check)
on zoo grounds

Other

18. Are records kept of all post mortem findings?
19. Is manure, unused feed and other waste from restricted animals
disposed of within zoo grounds? (If "yes" check)
Composted at least 6 months

Incinerated

Buried

20. Are restricted animal carcasses disposed
of within zoo grounds? (If "yes" check)
Incinerated

Buried

21. Is there an adequate area of zoo property where
restricted animals and manure could be buried??
22. Is there an adequate area of zpp property where restricted manure
could be composted for six months?
23. Is there an incinerator within the zoo property?
24. Will incinerator handle restricted animal wastes and carcasses?
25. Does zoo operate without any domestic livestock being used or
exhibited on zoo property?
26. Is surface run off such that it does not flow onto areas outside zoo
property which hold domestic livestock?
27. Are "65 series forms" in order and up to date?
28. SIGNATURE OF INSPECTOR

VS FORM 17-65A
(OCT 2005)

29. DATE OF INSPECTION

(OVER)

30. TABULATION OF RESTRICTED ANIMALS IN ZOO
TATTOO

SPECIES
READING
TATTOO

A

B

C

CHECKING
ZOO
RECORDS
D

31. COMMENTS OR REMARKS

32. SKETCH OF ZOO PROPERTY (Show area of restricted animal exhibits by shading)

VS FORM 17-65A (Reverse)

PRESENT STATUS

VERIFIED BY
OFFICIAL
STATEMENT
E

ON
ZOO
("X")
F

TRANSFERRED
TO

DIED
(Date)

G

H