VS 4-33 Brucellosis Test Record

According to the Paperwork Reduction Act of 1995, no persons are required to respond to, a collection of information unless it displays a valid OMB number. The
valid OMB control number for this information collection is 0579-0047 and 0579-0185. The time required to complete this collection of information is estimated to
average .16 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.

STATE

OMB Approved
0579-0047 and 0579-0185

ALL INCOMPLETE RECORDS WILL BE RETURNED FOR COMPLETION
COOPERATIVE STATE-FEDERAL BRUCELLOSIS ERADICATION PROGRAM

COUNTY

CODE

HERD NUMBER

HERD OWNER

PREMISES ID NO.

ROUTE STREET ROAD

BRUCELLOSIS TEST RECORD
LAST

FIRST

STATE

INITIAL

Slaughter
Rea

1

Hd. Cert/
Validation

6

Lvst. Mkt.
Rea

2

Post Move
Quar. Test

7

Susp. Ring
Test

3

COMPLETE HERD TEST OF ALL
ELIGIBLE ANIMALS
YES

SUMMARY
NEGATIVE

NO

8

NO. IN HERD

Area Test

5

9

Other
(Specify below)

10

REMARKS

KIND OF HERD
DAIRY

BEEF

SWINE

OTHER (Specify
below)

LABORATORY
PLACE

DATE LISTED
2

REA

SUS

FEE BASIS
(Federal)

(Owner’s
expense)

AGREE CODE

ROUTE-STREET-ROAD

DATE BLED

MIXED
REACTOR

DATE

AGE

PRIVATE

SIGNATURE

POST OFFICE

STATE

BREED

SEX

ZIP CODE

REACTORS TAGGED AND BRANDED
DATE:
SIGNATURE:

TOTAL

LABORATORY RESULTS
VACC
TATTOO

STATE
COUNTY

I CERTIFY:
That I have drawn blood samples from each animal identified below and have
correctly listed each tube number with corresponding identification number,
all numbers and letters of all eartags have been listed, cattle with existing
official eartags have not been retagged, and when payment is claimed at
program expense in accordance with agreement number below, no payment
has been or will be received from any other source.

BY:
RECORD ALL
IDENTIFICATION
NUMBERS(S)

TOTAL

SUSPECT

Epidemiology

Pvt. Sate

TUBE
NO.

FEDERAL
EMPLOYEE

ZIP CODE

GPS COORDINATES

RETEST

4
Diagnostic

VET CODE

CERTIFICATION F0R PAYMENT

POST OFFICE
REASON FOR TEST

PREVIOUS
TEST DATE

INITIAL

FLD
T

RAP

FPA

CARD

BAPA

CF

FIELD TEST
DONE BY:
AGREE CODE

TEST
IN TERP

REMARKS
AND
ADDITIONAL
INFORMATION

REACTOR
TAG NUMBER

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

RT – Retag
NA – Natural Addition
PA – Purchased Addition
AB – Aborter
VS FORM 4-33
JUL 2011

Record ALL
Eartag(s) and
Tattoo(s)

Record ALL
Legible
Characters

FIELD TEST
CODE
N – Negative
P – Positive

TEST INTERPRETATION
N – Negative Classified by:
S – Suspect___________________________
R – Reactor date Classified:

TEST
AUTHORIZATION
EXPIRES