Form VS-1-36A National Veterinary Accrediation Program Application For

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 0579-0297. The time required to complete this collection of information is estimated to average .5 hours 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.

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES

OMB Approved
0579-0297
Exp. XX/XXXX

1. Initial Accreditation

2. Authorization in a new State

State: ______

State: ______ License Number:___________________

License Number:___________________

3. Change Accreditation Category (Block 15 or 16)

4. Contact Information Change

5. Accreditation Renewal

6. Post-Revocation Re-Accreditation

NATIONAL VETERINARY ACCREDITATION PROGRAM

APPLICATION FORM
7. Name of Veterinarian (Last, First, M, Suffix):
9. Other Names Used (e.g., Maiden Name):

Check if your name has changed.
10. Date of Birth:

8. Six-Digit National Accreditation Number:
_____ _____

_____

11. School of Veterinary Medicine:

_____

_____

_____

12. Year Graduated:

14. Are you interested in participating in State or Federal agricultural emergency response efforts?

13. State where First Orientation Completed:

Yes

No

ACCREDITATION CATEGORY SELECTION select only one – Block 15 OR 16
15.

Category I animals (includes canines, felines, amphibians/reptiles, furbearing
animals, laboratory animals (rodents), and non-human primates)

16.

Refer to Explanation of Codes Page

Refer to Explanation of Codes Page

Practice Code(s):

3

4

8

9

Category II animals (includes all animals)

Practice Code(s):

(select up to two)

_______

Species Code(s):
1
2
12
16
17 (rodents)
18
(select up to four; this does not limit the number of Category I species upon which you may
perform accredited duties)

Species Code(s):

Primary Medical Discipline:

_______

Primary Medical Discipline:

_______

Employment Type:

_______

Employment Type:

_______

_____

_____

______

_______
_____

(list up to two)
(list up to four; this does not limit the
number of species upon which you
may perform accredited duties)

CONTACT INFORMATION
24. Name of Business:

17. Home Mailing Address:

25. Business Mailing Address:

18. City:

19. State:

20. ZIP Code:

26. City:

27. State:

21. County of Home Mailing Address:

29. County of Business Mailing Address:

22. Home Phone:

30. Business Phone:

23. Email Address:

31. Business Cell Phone:

28. ZIP Code:

32. Business FAX Number:

33. Please mark the Contact Information USDA may make available to the public:

34.
Module Number
35.

Home

Business

None

(select at least one)

ACCREDITATION RENEWAL OR CHANGE OF ACCREDITATION CATEGORY – Complete only if block 3 or block 5 are selected.
Enter the module numbers, not names, of the APHIS approved supplemental training modules you have completed.
Category I veterinarians: three modules; Category II veterinarians: six modules.

Course Type

36.

Date Module
Completed
By signing in block 37, I certify that the information contained in this form is true and correct to the best of my knowledge. I am able to perform the tasks listed in Title 9 Code of Federal Regulations (CFR)
Part 161.1(g) for the accreditation category designated in Blocks 15 or 16. I have been given a copy of the Standards of Accredited Veterinarian Duties contained in Title 9 CFR Part 161.4, and I agree to
conduct all activities as an accredited veterinarian in accordance with the Standards of Accredited Veterinarian Duties.
37. Signature of Veterinarian:
38. Date:
Signature of the Veterinarian-in-Charge and the State Animal Health Official appearing below denotes endorsement of the applicant for veterinary accreditation and/or authorization in a new State.
Signatures are NOT required for Accreditation Renewal or Change in Accreditation Category.
39. Signature of State Animal Health Official:
40. Date:

41. Signature of Veterinarian-in-Charge:

VS Form 1-36A
NOV 2012

42. Date:

Instructions for Completing VS Form 1-36A, National Veterinary Accreditation Program (NVAP) Application.
Block 1. Initial Accreditation: Check this block if you are applying for
initial accreditation. Enter the two-letter State abbreviation and your
complete veterinary license number for this State. Complete blocks 1, 7, 9
(if applicable), 10, 11, 12, 13, 14, 15/16, 17-33, 36, and 37.
Block 2. Authorization in a new State: Check this block if you are
seeking authorization to perform accredited duties in an additional State.
Enter the two-letter State abbreviation and your complete veterinary license
number for this State. Complete blocks 2, 7, 8, 9 (if applicable) 10, 17-33,
36, and 37.
Block 3. Change Accreditation Category: Check this block if you are
changing your Accreditation Category. Complete blocks, 3, 7, 8, 10, 15/16,
and 34-37.
Block 4. Contact Information Change: Check this block if you are
changing your contact information (e.g., name, address). Complete blocks
4, 7, 8, 10, and the appropriate CONTACT INFORMATION fields.
Block 5. Accreditation Renewal: Check this block if you are renewing
your accreditation. Complete blocks 5, 7, 8, 10, and 34-37. You may not
apply for renewal prior to 6 months of your renewal date.
Block 6. Post -Revocation Reaccreditation: Check this block if your
accreditation was revoked and you are applying for reaccreditation.
Complete blocks 6, 7, 8, 10, 15/16, 17-33, 36, and 37.
Block 7. Name of Veterinarian: Enter your legal last name, first name and
middle initial. (If this is a name change request, enter your new legal name
in this block.) Check the block, if your name has changed and complete
Block 9.
Block 8. Six-Digit National Accreditation No.: Enter the National
Accreditation Number that you have been assigned.
Block 9. Other Names Used (e.g., Maiden Name): Enter other names
used – for example, maiden name, nickname (this name should not be the
same name as in block 7).
Block 10. Date of Birth: Enter the two-digit month, two-digit day, and fourdigit year of your birth.
Block 11. School of Veterinary Medicine: Enter the name of the school
of veterinary medicine from which you graduated.
Block 12. Year Graduated: Enter your four-digit year of graduation from a
school of veterinary medicine.
Block 13. State where Orientation Completed: Enter the two letter
abbreviation of the State where core orientation was completed.
Block 14. Are you interested in participating in State or Federal
agricultural emergency response efforts? Check “yes” or “no”, if you
would like to be contacted to assist with agricultural emergency response
efforts.
Category Selection
(Refer to Explanation of Codes)
Block 15. Category I: Check this block for authorization to only perform
accredited duties on canines, felines, amphibians/reptiles, furbearing
animals, laboratory animals (rodents), and/or non-human primates.
Block 16. Category II: Check this block for authorization to perform
accredited duties on all animals.

Home Contact Information
Block 17. Home Mailing Address: Enter your complete home mailing
address. This is the address that will be used by NVAP to communicate
with you.
Block 18. City: Enter the city of your home address.
Block 19. State: Enter the two-letter state abbreviation of your home
address.
Block 20. ZIP Code: Enter the five- or nine-digit ZIP code of your home
address.
Block 21. County of Home Mailing Address: Enter the county in which
your home address is located.
Block 22. Home Phone: Enter your 10-digit home phone number.
Block 23. Email Address: Enter your email address. (NOTE: If you enter
a shared email address, that information may be viewed by others.)
Business Contact Information
Block 24. Name of Business: Enter the name of the business where you
work/practice. If you are self-employed without a specific business name,
enter your name from Block 7.
Block 25. Business Mailing Address: Enter complete business mailing
address. If your home mailing address is your business mailing address,
write “Same as home address.”
Block 26. City: Enter the city of your business address.
Block 27. State: Enter the two-letter state abbreviation of your business
address.
Block 28. ZIP Code: Enter the five- or nine-digit ZIP code of your business
address.
Block 29. County of Business Mailing Address: Enter the county in
which your business address is located.
Block 30. Business Phone Number: Enter your 10-digit business phone
number.
Block 31. Business FAX Number: Enter your 10-digit fax number.
Block 32. Business Cell Number: Enter your 10-digit cell phone number.
Block 33. Please mark the Contact Information you would permit the
USDA to share with the public: Choose at least one of the boxes
“Home”, “Business”, or “None” to indicate which information you grant
APHIS permission to provide to the public who are trying to locate an
accredited veterinarian.
Block 34. Module Number: Enter the module numbers, not the names, of
the APHIS approved supplemental training modules you have completed.
Category I veterinarians: three modules; Category II veterinarians: six
modules
Block 35. Course Type: Enter either Online, Lecture, CD, or Print. The
CD and Print designations indicate that you purchased a CD or printed
version of the module from the Center for Food Security and Public Health
at Iowa State University.

Species Code(s): Enter up to four code(s) associated with the species with
which you most often expect to perform accredited duties. These entries do
not limit the species on which you may perform accredited duties within
your Accreditation Category.

Block 36. Date Module Completed: Enter the two-digit month, two-digit

Practice Code(s): Enter up to two code(s) which most clearly describes the
species upon which you will perform accredited duties.

Block 37. Signature of Veterinarian: Read the certification statement
above block 36 and sign in blue or black ink. (NOTE: The applicant MUST
be licensed or legally able to practice as a veterinarian.)

Primary Medical Discipline: Enter the number associated with the
discipline that best describes your primary medical discipline.
Employment Type: Enter the number associated with your employment
type.
VS Form 1-36A
OCT 2012

day, and four-digit year that you completed the module.
Certification/Approval

Block 38. Date: Enter the two-digit month, two-digit day, and four-digit
year that you signed this application.
Blocks 39-42: Do not enter any information in these blocks.

PRIVACY ACT NOTICE
General:
This information is provided pursuant to Public Law 95-3579 (Privacy Act of 1974) December 31, 1974, for individuals completing the VS 1-36A.
Authority:
5 U.S.C. 3301, 7 U.S.C. 8309, and 21 U.S.C. 113a
Routine Uses:
The information will be used for (1) Referral to State Animal Health officials to certify accreditation status or to exchange information regarding disciplinary action(s). (2)
Referral to state veterinary examining boards to certify accreditation status or to exchange information regarding disciplinary action(s). (3) Disclosure to the public for the
purpose of locating and contacting accredited veterinarians for a specific geographical location. (4) Referral to the appropriate agency, whether Federal, State, local or
foreign, charged with the responsibility of investigating or prosecuting a violation of law, or of enforcing or implementing a statute, rule, regulation or order issued pursuant
there to, of any record within this system when information available indicates a violation or potential violation of law, whether civil, criminal or regulatory in nature, and
whatever arising by general statue or particular program statue, or by rule, regulation or order issued pursuant thereto. (5) Disclosure to the Department of Justice has
agreed to represent the employee or the United States, where the agency determined that litigation is likely to affect the agency or any of its components, is a party to litigation
or has an interest in such litigation and the use of such records by the Department of Justice is deemed by the agency to be relevant and necessary to the litigation ; provided,
however, that in each case the agency determines that disclosure of the records to be Department of Justice is a use of the information contained in the records that is
compatible with the purpose for which the records were collected. (6) Disclosure in a proceeding before a court of adjudicative body before which the agency is authorized to
appear, when the agency, or any component thereof, or any employee of the agency in his or her official capacity, or any employee of the agency in his or her individual
capacity where the agency has agreed to represent the employee or the United States, where the agency determines that litigation is likely to affect the agency or any of its
components, is a party to litigation or has an interest in such litigation, and the agency determines that use of such records is relevant and necessary to the litigation; provided,
however, that in each case the agency determines that disclosure of the records to the court is a use of the information contained in the records that is compatible with the
purpose for which the records were collected (7) Disclosure to appropriate agencies, entities, and persons when the agency suspects or has confirmed that the security or
confidentiality of information in the system of records has been compromised; the agency has determined that as a result of the suspected or confirmed compromise there is a
risk of harm to economic or property interests, a risk of identity theft or fraud, or a risk of harm to the security or integrity of this system or other systems or programs (whether
maintained by the agency or another agency or entity) that rely upon the compromised information; and the disclosure made to such agencies, entities, and persons is
reasonably necessary to assist in connection with the agency’s efforts to respond to the suspected or confirmed compromise and prevent, minimize, or remedy such harm; (8)
Disclosure to cooperative Federal, State, and local government officials, employees, or contractors, and other parties engaged to assist in administering the program. Such
contractors and other parties will be bound by the nondisclosure provisions of the Privacy Act. This routine use assists the agency in carrying out the program, and thus is
compatible with the purpose for which the records are created and maintained. (9) Disclosure to USDA contractors, partner agency employees or contractors, or private
industry employed to identify patterns, trends or anomalies indicative of fraud, waste, or abuse. (10) Disclosure to the National Archives and Records Administration or to the
General Services Administration for records management inspections conducted under 44 U.S.C. 2904 and 2906.
Effects of Nondisclosure:
Although this information is voluntary, failure to complete all the information may delay the process of the application or it may result in the application not being processed.

VS Form 1-36A
OCT 2012

Explanation of Codes
Species Codes (Blocks 15 & 16)
(May choose up to 4 codes)
1 - Canine
2 - Feline
3 - Equine
4 - Bovine
5 - Porcine
6 - Ovine/Caprine
7 - Camelid
8 - Cervid
9 - Poultry
10 - Avian (non-poultry)
11 - Exotics
12 - Amphibian/Reptile
13 - Aquatic Animal
14 - Zoo Animal
15 - Wildlife
16 - Furbearing Animals
17 - Laboratory Animal
18 - Non-Human Primate
19 - Human
20 - Other Species
21 - No Species Contact
Practice Codes (Blocks 15 & 16)
(May indicate up to 2 codes)
1 - Food Animal Predominant – sum of
Species Codes (4, 5, 6, 7, 8, or 9) is at
least 50% of contact
2 - Food Animal Exclusive – sum of
Species Codes (4, 5, 6, 7, 8, or 9) is at
least 90% of contact
3 - Companion Animal Predominant –
sum of Species Codes (1, 2, 10, or 11)
is at least 50% of contact
4 - Companion Animal Exclusive – sum of
Species Codes (1, 2, 10, or 11) is at
least 90% of contact
5 - Mixed Animal – varied species with at
least 25% from companion animal and
25% from either food animal or equine
6 - Equine Predominant – Species Code
(3) is at least 50% contact
7 - Equine Exclusive – Species Code
(3) is at least 90% contact
8 - Other
9 - No Species Contact
Primary Medical Disciplines
(Blocks 15 & 16)
(Choose only 1 discipline)
1 - Anatomy
2 - Anesthesiology

345678910 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 -

Animal Behavior
Animal Welfare
Alternative/Contemporary
Association Management
Biochemistry
Biomedical Engineering
Business/Economics
Cardiology
Dentistry
Dermatology
Disaster Medicine
Ecology
Emergency and Critical Care
Endocrinology
Environmental Health
Epidemiology
Ethics
General Medicine
Genetics
Human Animals Bond
Homeland Security
Immunology
Internal Medicine
Insurance
Laboratory Animal Medicine
Law
Media
Microbiology
Mycology/Bacteriology
Molecular Biology
Neurology
Non-Medical
Nutrition
Oncology
Ophthalmology
Parasitology
Pathology - Anatomic
Pathology – Clinical
Pharmacology
Pharmacology – Clinical
Physiology
Population Medicine
Poultry Medicine
Preventative Medicine
Production Medicine
Public Health
Radiology
Shelter Medicine
Sports Medicine
Surgery
Theriogenology
Toxicology
Virology

56 - Wildlife Medicine
57 - Zoological Medicine
58 - Other Professional Discipline
Employment Type (Blocks 15 & 16)
(May choose only 1 type)
Private Clinical Practice
1 - General Medicine/Surgery
2 - Production Medicine
3 - Referral/Specialty Medicine
4 - Emergency/Critical Care Medicine
5 - Other Private Clinical Practice
Academia
6 - Veterinary Medical College/School
7 - Veterinary Science Department
8 - Veterinary Technician Program
9 - Animal Science Department
10 - Other Academia
Government
11 - U.S. Federal
12 - State
13 - Local
14 - Foreign
15 - Army
16 - Air Force
17 - Public Health Commission Corps
18 - Other Government
Industry/Commercial
19 - Pharmaceutical/Biological
20 - Feeds/Nutrition
21 - Laboratory
22 - Agriculture/Livestock Production
23 - Business/Consulting Services
24 - Other Industry/Commercial
Other
25 - Humane Organization
26 - Membership Assn/Professional
Society
27 - Foundation/Charitable Organization
28 - Missionary/Service
29 - Zoo/Aquarium
30 - Wildlife
32 - Temp Not Employment in Veterinary
Field
33 - Non-Veterinary Employment
34 - Not Employed
35 - Not Listed Above

This Professional Classification System is used courtesy of the American Veterinary Medical Association.

VS Form 1-36A
OCT 2012