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 0579-0237. The time required to complete this
information collection is estimated to average 1 hour 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
0579-0237
EXP.:
XX/XXXX
UNITED
STATES DEPARTMENT OF AGRICULTURE
ANIMAL
AND PLANT HEALTH INSPECTION SERVICE
VETERINARY
SERVICES
APPLICATION
FOR CHRONIC WASTING DISEASE HERD CERTIFICATION PROGRAM (CWD HCP)
APPROVAL, RENEWAL, OR REINSTATEMENT OF A STATE
1.
STATE
2.
APPLICATION FOR (“X” one)
APPROVED STATUS
RENEWAL OF APPROVED STATUS
REINSTATEMENT OF APPROVED STATUS
3.
REPORTING PERIOD:
4.
STATUS OF ACTION ITEMS IDENTIFIED ON THE LAST RENEWAL OR AS
PART OF AN APPROVED STATE REVIEW
(Use
an attachment sheet, if necessary)
5.
QUALIFICATION (“X”
all that apply)
A.
The requirements of 9 CFR 55.23 (a)
have been met. State CWD HCP regulations, program policies and
standards, legal authorities, and other supporting documentation
are attached. (The
supporting documentation must describe which requirement(s) of 9
CFR 55.23 are being met.)
B.
The CWD National Database OR an
equivalent State database to maintain CWD HCP data is updated as
needed and data are current, accurate and complete for the
reporting period.
C.
The
annual Approved State CWD HCP Report has been completed and
submitted to the VS Regional Office.
6.
INVENTORY OF ENROLLED HERDS
A.
TOTAL NO. OF ENROLLED DEER HERDS
B.
TOTAL NO. OF ENROLLED ELK HERDS
C.
TOTAL NO. OF DEER ENROLLED IN HCP
D.
TOTAL NO. OF ELK ENROLLED IN HCP
Comments
(Note any mixed herds, etc):
7.
SURVEILLANCE ACTIVITIES
Number
of animals tested through on-farm surveillance
Number
of animals tested at slaughter
C.
Number of animals tested at hunt facilities (shooter
operations)
CERTIFICATION
The
provisions of 9 CFR Parts 55 and 81 have been met. APHIS requests
that this State be designated an Approved State CWD HCP.
8.
Signature of State Official
9.
Please Type or Print Name
10.
Date
11.
Signature of Area Veterinarian in Charge
12.
Please Type or Print Name
13.
Date
14.
Approval by VS Region
Application for Approved Status is complete and approved
Renewal of Approved Status is approved
Reinstatement of Approved Status is approved.
Form is being returned for completion or correction
Renewal or Reinstatement of Approved Status is provisionally
approved contingent on the conditions listed in the attachment
being met by the following date: ________________
15.
Signature of Regional Epidemiologist
16.
Please Type or Print Name
17.
Date
18.
Veterinary Services hereby declares the above State Approved for
the period beginning _______________ and ending
________________