VS 4-24 Calfhood Vaccination Record - Short Form

Brucellosis Program

VS 4-24 Mar 2009

Brucellosis Program - Business

OMB: 0579-0047

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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



U.S DEPARTMENT OF AGRICULTURE

ANIMAL AND PLANT HEALTH INSPECTION SERVICE

VETERINARY SERVICES

COUNTY


CODE

HERD NUMBER


HERD OWNER LAST FIRST INITIAL



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

EMPLOYEE

FEE

BASIS

(Federal)

STATE

COUNTY

PRIVATE (Owner’s

Expense)

REMARKS

WBBS

CV AV


RGE

TWP

SEC

DISTRICT

FARM UNIT

I CERTIFY THAT: (1) I have vaccinated with Strain 19, tattooed and eartagged or otherwise properly identified all

NO.

IDENTIFICATION

NUMBER

AGE

(MO/YR.)

BREED

SEX

P/B-

GRADE

*

TATTOO

animals listed hereon as prescribed by the Brucellosis UM and R, and recorded all information as prescribed by State regulations; (2) 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.

1.







2.







Signature



Date of Vacc-ination

Agree. Code

3.







CERTIFICATION OF OWNER OR WITNESS

I CERTIFY THAT the animals listed hereon were vaccinated and identified for the above named owner.

4.







5.







Signature



Date

6.







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.

7.







Signature


Date

8.







VS FORM 4-24 Previous edition may be used

MAR 2009

Copy designationS


Part 1 – Office

Part 2 – office

Part 3 – owner

Part 4 – Veterinarian

File Typeapplication/msword
File TitleSTATE
AuthorGovernment User
Last Modified ByKhbrown
File Modified2009-04-14
File Created2009-04-14

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