Vs 16-78 Report of Entry, Shipment of Restricted Imported Animal

Highly Pathogenic Avian Influenza, All Subtypes, and exotic Newcastle disease; additional restrictions

2011 VS 16-78

Business and Not-For-Profit

OMB: 0579-0367

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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 OMB control number for this information collection is 0579-0367. The time required to complete this information collection is estimated to average .5 minutes 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

0579-0367

UNITED STATES DEPARTMENT OF AGRICULTURE

ANIMAL AND PLANT HEALTH INSPECTION SERVICE

VETERINARY SERVICES

REPORT OF ENTRY, SHIPMENT OF RESTRICTED IMPORTED ANIMAL PRODUCTS AND ANIMAL BY-PRODUCTS, AND OTHER MATERIAL

1. CASE NO.


2. PORT OF ENTRY

A. REPORT OF ENTRY AND FORWARDING OF SHIPMENT FROM FIRST PORT OF ARRIVAL

3. NAME AND ADDRESS OF IMPORTER OR SHIPPER (Include ZIP Code)







4. COUNTRY OF ORIGIN



5. CUSTOMS ENTRY NO.

6. PRODUCT OR MATERIAL



7. DATE OF ARRIVAL


8. VETERINARIAN IN CHARGE IN STATE WHERE APPROVED ESTABLISHMENT IS LOCATED (Include ZIP Code)

9. NAME OF VESSEL




10. NAME OF CARRIER (Include R.R. Car No. or Truck License No.)




11. SEAL NOS. OR QUARANTINE TAPE


12. TOTAL QUANTITY RECEIVED AT PORT OF ARRIVAL (Lbs. only)

13. NO. UNITS RECEIVED AT PORT OF ARRIVAL (Specify Carton, Boxes, Bundles, etc.,)



14. NAME AND ADDRESS OF APPROVED ESTABLISHMENT (Include ZIP Code and phone no.)







FROM PORT OF ENTRY TO

APPROVED ESTABLISHMENT

15. NO. LBS.

16. NO. UNITS

17. REMARKS









18. PRINTED NAME AND SIGNATURE OF INSPECTOR





19. PPQ STATION

20. DATE

B. REPORT OF RECEIPT AND TREATMENT BY ESTABLISHMENT (To be completed by Approved Establishment)

21. DATE RECIEVED

22. NAME OF APPROVED ESTABLISHMENT



23. WAS SHIPMENT INTACT


Yes No (If “No” explain in item 30)

24. DATE TREATMENT COMPLETED



25. WERE R.R. CARS, TRUCKS, ETC. CLEANED AND DISINFECTED? Yes No

26. DISINFECTANT USED

27. METHOD OF TREATMENT







28. DISPOSITION OF REFUSE



29. REMARKS









30. PRINTED NAME OF APPROVED ESTABLISHMENT OWNER



31. SIGNATURE OF APPROVED ESTABLISHMENT OWNER

32. DATE

VS FORM 16-78

APR 2009





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 OMB control number for this information collection is 0579-XXXX. The time required to complete this information collection is estimated to average .5 minutes 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-XXXX

UNITED STATES DEPARTMENT OF AGRICULTURE

ANIMAL AND PLANT HEALTH INSPECTION SERVICE

VETERINARY SERVICES

REPORT OF ENTRY, SHIPMENT OF RESTRICTED IMPORTED ANIMAL PRODUCTS AND ANIMAL BY-PRODUCTS, AND OTHER MATERIAL

1. CASE NO.


2. PORT OF ENTRY

A. REPORT OF ENTRY AND FORWARDING OF SHIPMENT FROM FIRST PORT OF ARRIVAL

3. NAME AND ADDRESS OF IMPORTER OR SHIPPER (Include ZIP Code)







4. COUNTRY OF ORIGIN



5. CUSTOMS ENTRY NO.

6. PRODUCT OR MATERIAL



7. DATE OF ARRIVAL


8. VETERINARIAN IN CHARGE IN STATE WHERE APPROVED ESTABLISHMENT IS LOCATED (Include ZIP Code)

9. NAME OF VESSEL




10. NAME OF CARRIER (Include R.R. Car No. or Truck License No.)




11. SEAL NOS. OR QUARANTINE TAPE


12. TOTAL QUANTITY RECEIVED AT PORT OF ARRIVAL (Lbs. only)

13. NO. UNITS RECEIVED AT PORT OF ARRIVAL (Specify Carton, Boxes, Bundles, etc.,)



14. NAME AND ADDRESS OF APPROVED ESTABLISHMENT (Include ZIP Code and phone no.)







FROM PORT OF ENTRY TO

APPROVED ESTABLISHMENT

15. NO. LBS.

16. NO. UNITS

17. REMARKS









18. PRINTED NAME AND SIGNATURE OF INSPECTOR





19. PPQ STATION

20. DATE





























__________________________________________________________________________________________________________________________________________

VS FORM 16-78

APR 2009





COPY DESIGNATIONS

BOTTOM RIGHT CORNER- RED INK


PART 1 – ORIGINAL


PART 2 – SHIPPING COPY (To accompany shipment)


PART 3 – VETERIANARIAN IN CHARGE


PART 4 – INSPECTOR’S FILE COPY (Where prepared)







******NOTE FOR PRINTING


PARTS 1 AND 2 – FULL SHEET TO NO. 32


PARTS 3 AND 4 – STOPS AT NO. 20


CARBON TO STOP AT THE BOTTOM LINE OF NOS. 18, 19, AND 20.


GLUED ACROSS TOP WITH PERFORATED STUB


** SEE SPEC SHEET FOR MORE INFOR**

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File TitleAccording to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor and a person is not required to respond t
Authorkahardy
Last Modified Bykahardy
File Modified2011-07-26
File Created2011-07-26

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