VS 4-26 Vaccination Record - Long Form

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 0579-0047. The time required to complete this information collection is estimated to average .083 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.

OMB APPROVED 0579-0047

STATE

ALL VACCINATIONS MUST BE PROMPTLY REPORTED COOPERATIVE STATE-FEDERAL BRUCELLOSIS ERADICATION PROGRAM BRUCELLOSIS VACCINATION RECORD

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

COUNTY

CODE

HERD NUMBER

HERD OWNER (LAST NAME, FIRST NAME, MI)

VACCINE USED

EXPIRATION DATE

OWNER NUMBER

ROUTE-STREET-ROAD

SERIAL NUMBER

DOSAGE FULL REDUCED

VACC.TATTOO

KIND OF HERD DAIRY BEEF MIXED

POST OFFICE STATE ZIP CODE

CERTIFICATION FOR PAYMENT FEDERAL FEE BASIS STATE PRIVATE EMPLOYEE (Federal) COUNTY (Owner’s Expense) I CERTIFY THAT: (1) I have vaccinated with Strain 19, tattooed and eartagged or otherwise properly identified all animals listed hereon as

REMARKS

WBBS

CV AV

RGE

TWP

SEC

DISTRICT

FARM UNIT

NO.

IDENTIFICATION NUMBER

AGE

BREED

SEX

P/B GRADE

* TATTOO

prescribed by the Brucellosis UM and R, and recorded all information as prescribed by State regulations; and (2) when payment is claimed at the program’s expense in accordance with the agreement number below no payment has been or will be received from any other source.

Yr. (s)

Mo. (s)

1

Signature

Date of Vaccination

Agree. Code

2

CERTIFICATION OF OWNER OR WITNESS I CERTIFY THAT the animals listed hereon were vaccinated and identified for the above named owner.

3

Signature

Date

4

CERTIFICATION FOR RE-ESTABLISHING VACCINATION STATUS * Indicate tattoo of animals previously vaccinated in appropriate column. I CERTIFY THAT I have personally examined the animal(s) noted hereon, and have read the official tattoo(s), and have retagged them as shown.

5

6

Signature

Date

7

NO.

IDENTIFICATION NUMBER

AGE

BREED

SEX

P/B GRADE

* TATTOO

Yr.(s)

Mo.(s)

8

20

9

21

10

22

11

23

12

24

13

25

14

26

15

27

16

28

17

29

18

30

19

31

VS 4-26 AUG 2012

Copy Designations

Part 1-Office

Part 2-Office

Part 3-OWNER

Part 4-Veterinarian