Form VS 17-140 VS 17-140 United States Origin Health Certificate

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 numbers for these information collections are 0579-0020, 0101, 0156, and 0278. The times required to complete these information collections is estimated to average .5 to 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.
This certificate is authorized by law (21 U.S.C. 112); while you are not required to respond, no health certificate can be validated unless the data requested is provided.
UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES

1. CONSIGNOR’S NAME (Last name, First name, Middle initial, or Business name) 2. CERTIFICATE NUMBER

UNITED STATES ORIGIN HEALTH CERTIFICATE
(This document does not replace the Certificate of Inspection of Export Animals, VS Form 17-27)
5. U.S. PORT OF EMBARKATION (City and State)
4. DATE ISSUED
6. STATE CODE

11. TRANSPORTATION CLASS
1 - Rail
3 - Air
2 - Truck
4 - Ocean

10. NO. DOSES OF SEMEN

3. PAGE NUMBER

1
7. CONSIGNOR'S STREET ADDRESS (Mailing Address)

OF

8. CONSIGNOR'S CITY (or Town)

12. CONSIGNOR'S STATE
9. SEMEN ("X" if yes)

OMB Approved
0579-0020, 0101,
0156, and 0278

13. STATE CODE

16. CONSIGNEE'S NAME AND STREET ADDRESS (Mailing Address)

14. ZIP CODE

DESTINATION COUNTRY

ENTER CODE

15. SPECIES ("X" one - use VS Form 17-6 for Poultry)
01 BOVINE

02 PORCINE
05 EQUINE

03 OVINE

NEGATIVE TUBERCULIN
READING

04 CAPRINE

48 HRS

09 OTHER (Specify)
If more lines are needed below - use VS Form 17-140A
17. FARM ORIGIN
Owner's name (Last name, Two initials, or Business name)
Owner's street address, Owner's city/town, State code.
(FIPS code on reverse) & ZIP Code

VALID ONLY IF USDA VETERINARY SEAL
APPEARS HERE

BRUCELLOSIS BLOOD SAMPLE
COLLECTED

NEGATIVE RESULTS OF OTHER TESTS

08 OTHER WILDLIFE – MAMMAL
72 HRS

CERTIFIED BRUCELLOSIS
FREE AREA

MODIFIED ACCREDITED AREA (TB)
18. INDIVIDUAL IDENTIFICATION

DISEASE

DISEASE

DISEASE

TYPE TEST

TYPE TEST

TYPE TEST

DATE
M

DATE
N

DATE
O

(Instructions for columns A, B, C & D on reverse)
ID NO. OR DESCRIPTION
A

AGE
B

SEX
C

BREED
D

√
E

DATE
F

√
G

DATE
H

VAC
I

1/25
J

1/50
K

1/100
L

CERTIFICATION BY ISSUING VETERINARIAN
This is to certify that the animals identified above were inspected by me on this date and found to be free from evidence of communicable diseases and insofar as can be determined
exposure thereto; the premises of origin are not under Federal or State quarantine because of animal disease; the animals were all negative to the tests shown on the dates indicated.
Arrangements have been made for the animals to be handled in a transporting vehicle that has been cleaned and disinfected since last used for livestock and for movement to the port of
embarkation without exposure to other animals en route, except those meeting these health requirements. The shipment must be accompanied to the port of export with this certificate.
20. NAME OF ISSUING VETERINARIAN (Last name, First name, Middle initial,19. DATE ENDORSED
22. TOTAL NO. OF ANIMALS
21. STATUS
2 Federal
(Certified for export or donated
please print)
1 State

24. NAME OF ENDORSING FEDERAL VETERINARIAN (Type, Print, or Stamp)

23. Signature of Endorsing Federal Veterinarian
VS Form 17-140
SEP 2010

25. SIGNATURE OF ISSUING VETERINARIAN

3 Accredited

semen) (Include numbers from
all attached VS Forms 17-140A)

INSTRUCTIONS FOR COMPLETING VS FORM 17-140, UNITED STATES ORIGIN HEALTH CERTIFICATE
AND
VS FORM 17-140A. CONTINUATION SHEET FOR UNITED STATES ORIGIN HEALTH CERTIFICATE
Use a separate form for each Species. If additional lines are needed, use as many VS Forms 17-140A and B, Continuation Sheet for United States Origin Health Certificate, as needed If more copies of
this certificate are needed, duplicated copies may be made after endorsement, using any copy except the original. No additions, changes or deletions will be made on this certificate unless initialed by the
issuing, endorsing, or port veterinarian. (A double ruled line will be used to delete animals not being shipped.)
1.

Self-explanatory.

6.

STATE CODE - See FIPS state codes below.

2.

CERTIFICATE NO. - The Imprinted certificate no. on
the Certificate shall not be altered or crossed out,
and all copies covering the same Species shall carry
the same unaltered certificate no. Insert this no. on
all VS Forms 17-140A used.

7.

Self-explanatory.

8.

Self-explanatory.

9.

SEMEN - Check If Semen, but be certain to give
the Species in Item 15.

3.

4.

5.

PAGE NO. - Show total number pages In the
shipment on each sheet, (I.e., a shipment which
would use one VS Form 17-140 and two VS Form
17-140A would be numbered: "Page 1 of 3; Page 2
of 3; and Page 3 or 3).
DATE ISSUED - The date the veterinary Inspection
is completed.
U.S. PORT OF EMBARKATION - The point of
loading for export

15. SPECIES - (Check or Specify) - A separate certificate
must be used for each species.
16. Enter name and address of consignee and FIPS
country code.
17. Self-explanatory. (FIPS State Codes Below)
18. A - ID NO. OR DESCRIPTION - Show the complete
ear tag or tattoo no.

10. Self-explanatory.
11. Self-explanatory.

B - AGE - Age measured In months.

12. Self-explanatory

C - SEX - M-Male

F-Female

N-Neuter

13. STATE CODE - See FIPS state codes below
14. Self-explanatory

18D - BREEDS
BOVINE
AN - Aberdeen Angus
AB - Abondance
AF - Alfokander
AY - Ayahlre
BA - Barzona
BE - Beefalo
BF - Beef Friesian
BM - Beef Master
BB - Belgium Blue
BG - Belter Galloway
BD - Blonde D’Aquitaine
BO - Bradford
BR - Brahman
BH - Brahmental
BN - Brangus
SB - Brown Swiss (beef)
BS - Brown Swiss (dairy)
CP – Campine Red Pied

CN - Canadienne
CH - Charolais
CA - Chianina
DB - Danish Black
and White
DJ - Danish Jersey
RW - Danish Red
and White
DE - Devon
DR - Dexter
FP - East Flemish
Red Pied
ER - Eringer
FA - Flamand
FL - Fleckvieh
FR - Fribourg
FB - Friesian (Belgium)
DF - Friesian (Dutch)

GA - Galloway (beef)
GD - Galloway (dairy)
GS - Gascone
GV - Gelbvieh
GR - Groninger
GU - Guernsey
HC - Hays Converter
HH - Hereford (horned)
HP - Hereford (polled)
SH - Highland (Scotch
Highland)
HO - Holstein
HY - Hybrid (Alberta
Hybrid)
JE - Jersey
KB - Kobe (Wagyu)
LU - Luing
LM - Limousin

LR - Lincoln Red
MA - Maine-Anjou
MR - Marchigiana
ME - Maremmana
MI - Meuse-Rhine-Ijessel
MO - Montbellard
MG - Murray Gray
NM - Normandle
NR - Norwegian Red
PA - Parthenais
PI - Pinzgauer
RA - Ranger
AR - Red Angus
RB - Red Brangus
RD - Red Dane (Red
Danish, Danish Red)
WW - Red Holstein
RP – Red Poll

RN - Romagnola
RO - Rotbunte
AS - Salers
SG - Santa Gertrudis
MS - Shorthorn (milking)
SS - Shorthorn (beef-Scotch)
SP - MS - Shorthorn (polled)
IS - Shorthorn (Iliawarra)
SM - Simmental
DS - South Devon
SX - Sussex
TA - Tarentaise
TG - Tasmanian Grey
TL - Texas Longhorn
WB - Welsh Black
WF - West Flemish Red
XX -Crossbreds

PORCINE
CAPRINE
YO - Yorkshire
PC - Poland China
TM - Tamworth
AL - Alpine
LA - Landrace
BK - Birkshire
WS - Wessex Saddleback
AG - Angora
HA - Hampshire
SO - Spotted
LW - Large White (British)
LN - La Mancha
DU - Durec
CW - Chester White
LB - Large Black (British)
NU - Nubian
LC - Lacombe
PE - Pietrain
TO - Toggenburg
OVINE
BC - Border Cheviot
LE - Leicester
RA - Rambouillet
CO - Columbia
LI - Lincoln
RM - Romnelet
CR - Corriedale
MT - Montadale
SB - Scottish Blackface
DO - Dorset
NC - N. Country Cheviot
SR - Shropshire
FN - Finnish Landrace
OX - Oxford
ST - Southdown
HA - Hampshire
SU - Suffolk
EQUINE
AS - American Saddlebred
HU - Hunter
SI - Shire
AP - Appalosa
MN - Morgan
SN - Standardbred
AB - Arabian
APL - Palomino
SF - Suffolk Punch
BL - Belgian
PE - Percheron
TW - Tennessee Walking
CL - Clydesdale
PN - Pinto
TH - Thoroughbred
HA - Hackney (Horse)
OH - Quarter Horse
WE – Welsh
HK - Hackney (pony)
SE - Shetland

COLUMNS E-O
I - VAC - Use “OV” official vaccinates, or vaccination
date when required by country or destination.

E, F, G, H, - Self-Explanatory

J, K. L - Show Negative In highest Titer required.

M, N, O, - Self-Explanatory

FIPS STATE CODES (Items 6, 13, and 17)
01 - Alabama
02 - Alaska
03 - Arizona
04 - Arkansas
06 - California

08 - Colorado
09 - Connecticut
10 - Delaware
11 – Dist. of Columbia
12 - Florida

VS FORM 17-140 (Reverse)

13 - Georgia
15 - Hawaii
16 - Idaho
17 - Illinois
18 - Indiana

19 - Iowa
20 - Kansas
21 - Kentucky
22 - Louisiana
23 - Maine

24 - Maryland
25 - Massachusetts
26 - Michigan
27 - Minnesota
28 - Mississippi

29 - Missouri
30 - Montana
31 - Nebraska
32 - Nevada
33 - New Hampshire

34 – New Jersey
35 – New Mexico
36 – New York
37 – North Carolina
38 – North Dakota

39 - Ohio
40 - Oklahoma
41 - Oregon
42 - Pennsylvania
43 - Puerto Rico

44 - Rhode Island
45 - South Carolina
46 - South Dakota
47 - Tennessee
48 - Texas

49 - Utah
50 - Vermont
51 - Virginia
52 - Virgin Island
53 - Washington

54 - West Virginia
55 - Wisconsin
56 - Wyoming