APHIS/CDC Form 4C Reporting the Identification of a Select Agent or Toxin:

reporting the identification of A SELECT AGENT or TOXIN: federal law enforcementseizure report (APHIS/CDC Form 4C)

FORM APPROVED OMB NO. 0579-0213 OMB NO. 0920-0576 EXP DATE XX/XX/XXXX

INSTRUCTIONS

Read guidance instructions at www.selectagents.gov before completing this form. Answer all items completely and type or print in ink. The form must be signed and submitted to either APHIS or CDC by email attachment, fax, or mail:

Animal and Plant Health Inspection Service Agricultural Select Agent Program 4700 River Road Unit 2, Mailstop 22, Cubicle 1A07 Riverdale, MD 20737 FAX: (301) 734-3652 E-mail: [email protected]

C Accession Number(s): (For Program use ONLY) enters for Disease Control and Prevention Division of Select Agents and Toxins 1600 Clifton Road NE, Mailstop A46 Atlanta, GA 30333 FAX: (404) 718-2096 Email: [email protected]

Submit completed form only once by either email, fax, or mail

SECTION A – FEDERAL LAW EMFORCEMENT INFORMATION
1. Name of federal law enforcement agency:			2.Name of federal law enforcement agent: First: MI: Last:
3.Telephone #:	4.Fax #:		5.Email address:
SECTION B – SELECT AGENTS AND TOXINS SEIZED
1.Name of entity select agent or toxin seized from:
2.Select agent or toxin seized		3.Amount seized		4.Disposition of seized select agent or toxin
5. Were any of the seized select agents or toxins handled outside of primary containment which may have led to an unintentional release and/or exposure to the select agent or toxin?  No  Yes (If Yes, you are required under 7 CFR Part 331.19, 9 CFR Part 121.19, and 42 CFR Part 73.19 to complete and submit an APHIS/CDC Form 3)
6.Comments / Notes:

I hereby certify that the information contained on this form is true and correct to the best of my knowledge. I understand that if I knowingly provide a false statement on any part of this form, or its attachments, I may be subject to criminal fines and/or imprisonment. I further understand that violations of 7 CFR 331, 9 CFR 121, or 42 CFR 73 may result in civil or criminal penalties, including imprisonment.

Signature of Agent: ___________________________________________________ Date Signed: _______________________________

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 0579-0213. 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.