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Plant Health
Inspection
Service
Veterinary
Services
Highly Pathogenic Avian Influenza
(HPAI) Investigation - Questionnaire
INSTRUCTIONS
The purpose of these investigations is to assess potential pathways of initial introduction of
HPAI viruses onto commercial poultry operations and potential lateral transmission routes of
HPAI viruses from infected premises to noninfected premises.
Following confirmation of an HPAI virus introduction into a commercial flock, an investigation
should be initiated as soon as possible, no later than 1 week following detection. The
investigator(s) assigned should be integrated into other response activities but their primary
focus is on completion of the introduction investigation.
The Investigation Questionnaire provided is a guide for conducting a systematic and
standardized assessment of potential pathways of initial virus movement onto the farm and
potential movement of the virus off the farm. All sections of the form should be completed
through direct conversation with the individual(s) most familiar with the farm’s management and
operations and questions are to be answered for the period 2 weeks prior to the detection of
HPAI. Where applicable, direct observation should be conducted of the biosecurity or
management practice asked about in this questionnaire. This is not a box-checking exercise but
an in-depth review of the current biosecurity and management practices and exposure risks on
an affected farm. For example, direct observation of the farm’s employee donning and doffing
procedures and compliance with company biosecurity practices are more important than
checking the box on the form that indicates workers wear coveralls into the poultry houses.
Investigators are encouraged to take notes and include them with the Investigation
Questionnaire when completed.
An Investigation Questionnaire should be completed for the infected house or farm and at least
one noninfected house or farm within the same complex as near as possible to the index
infected flock.
VS Form 17-5
APR 2015
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 0579-0376. The time required to
complete this information collection is estimated to average 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.
UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES
Interviewer name/organization
OMB Approved
0579-0376
Exp.
09/2017
HPAI INVESTIGATION QUESTIONNAIRE
Interviewee name/organization
Date
A. PREMISES INFORMATION
Farm name
Farm (premises) ID
Farm address
County
Township
Range
Section
Is this facility enrolled in the National
Poultry Improvement Plan (NPIP)?
Yes
No
B. PREMISES CONTACT INFORMATION
1. Contact name
Phone
Email
Cell phone
2. Contact name
Phone
Email
Cell phone
3. Contact name
Phone
Email
Cell phone
4. Flock Veterinarian
Phone
Email
Cell phone
C. PREMISES DESCRIPTION
1. Poultry type
Broiler
2. Production type
Layer
Turkey
Other (specify: _____________________)
3. Age
Meat
Egg
4. Sex
Multiple age
Single age
Hen
Breeding
Other (specify: _____________________)
5. Flock size
Tom
Number of birds _____________
Both
6. Facility type (check all that apply)
7. If brooder and grower houses are present on the same premises, are there
multiple stages of management (brooding and growing), in the same house?
Brood
Yes
Grow
No
Other (specify: _____________________________________________)
8. Farm capacity
Both brooder and grower houses are present on the same premises
Breeder
Commercial
_____________ Number of birds
Number of barns
_____________ Number of barns
Barn capacity
_____________ Number of birds
9. What is the primary barn type/ventilation (check one only)
Curtain sided
Environmental control
10. Are cool cell pads used?
Yes
Side doors
Other (specify: _____________________________________)
No
If Yes, what is the source of water for these pads? _______________________________
12. Water body type (check all that apply)
11. Distance in yards of closest body of water near farm
_____________ Yard
13. What is the primary water source for poultry? (check one only)
Pond
Municipal
Lake
Well
Stream
Surface water (e.g., pond)
River
Other (specify: ___________________________________________)
Other (specify: __________________________________)
VS Form 17-5
APR 2015
Page 1 of 5
C. PREMISES DESCRIPTION (Cont.)
14. What other types of animals are present on the farm?
a.
Beef cattle ................................................................................................................................................................
Yes
No
b.
Dairy cattle ...............................................................................................................................................................
Yes
No
c.
Horses .....................................................................................................................................................................
Yes
No
d.
Sheep ......................................................................................................................................................................
Yes
No
e.
Goats .......................................................................................................................................................................
Yes
No
f.
Pigs ........................................................................................................................................................................
Yes
No
g.
Dogs ........................................................................................................................................................................
Yes
No
h.
Cats ........................................................................................................................................................................
Yes
No
i.
Poultry or domesticated waterfowl ..........................................................................................................................
Yes
No
j.
Other (specify: ___________________________________________________________________________)
Yes
No
15. Is water treated prior to delivery to poultry? .........................................................................................................................
If Yes, how is it treated and with what? __________________________________________________________________________
D. FARM BIOSECURITY
1. Is there a house with a family living in it on the property?
2. Is there a common drive entrance to farm and residence?
No
Yes
Yes
3. Do you have signage of “no admittance” or “biosecure area” on this property?
Yes
No
5. Is the gate secured/locked?
Yes
Yes
Yes
7. How frequently is vegetation mowed/bush hogged on the premises?
Yes
9. Is there a wash station/spray area available for vehicles?
Yes
No
If Yes, what disinfectant is used? ___________________________________
11. Is there a changing area for workers?
Yes
No
Do they shower?
Yes
No
10. Is there a designated parking area for workers and visitors away from the
barns/pens?
Yes
Yes
No
15. Are foot pans available at barn/pen entrances?
Yes
No
Are they in use?
Yes
No
17. Are foot baths liquid disinfectant?
No
19. Is there an entry area in the barns/pens before entering the bird area?
No
Are biosecurity audits or assessments (company or third party) conducted on this
farm?
Yes
No
No
12. Do workers don dedicated laundered coveralls before entering each house on the
premises?
13. Do workers wear rubber boots or boot covers in poultry houses?
Yes
No
8. Is the facility free of debris/clutter/trash piles?
____________ times/month
Yes
No
6. Is the farm area fenced in?
No
If Yes, what hours is it secured? __________________________________
Yes
No
4. Is there a gate to this farm entrance?
No
No
14. Are the barn/pen doors lockable?
Yes
No
Are they routinely locked?
Yes
No
16. Are foot baths dry (powdered or particulate disinfectant)?
Yes
No
18. Frequency foot pan solutions are changed?
_____________ times/month
What disinfectant is used? ______________________________________
20. What pest and wildlife control measures are used on this farm?
a. Rat and mouse bait stations
Yes
No
b. Bait stations checked at least every 6 weeks
Yes
No
c. Fly control used
Yes
No
If Yes, type and frequency:
__________________________________________
If Yes, when was the last audit or assessment conducted? ____________________
(Obtain a copy of the result of the audit or assessment if available.)
d. Houses are bird proof
21. Has this farm been confirmed positive for HPAI?
f. Raccoons, possums, or foxes seen in or around poultry
houses
g. Wild turkeys, pheasants, or quail seen in or around poultry
houses
Yes
No
e. Wild birds seen in house
If Yes, type, number, and frequency: ____________________________________
Yes
VS Form 17-5
APR 2015
No
Yes
Yes
No
No
Page 2 of 5
E. FARM HELP/WORKERS
1. Total number of persons working on farm
2. Number of workers living on the farm premises who are:
____________ Number
3. Workers are assigned to (check one only)
a.
Family
__________ Number
b.
Nonfamily
__________ Number
4. Do the workers have a common break area?
Yes
No
Entire farm
If Yes, location: __________________________________________________
Specific barns/areas
5. Are workers employed by other poultry operations?
Yes
6. How often are training sessions held on biosecurity for workers?
No
____________ times/year
7. Are family members employed by other poultry operations or processing plants?
Yes
No
8. Do part-time/weekend help and other extended family members on holidays and
vacations?
If Yes, poultry operation or processing plant: _______________________________
Yes
No
9. Are workers (full and part time) restricted from being in contact with backyard poultry?
Yes
No
How is this communicated? ________________________________
F. FARM EQUIPMENT
Is the equipment used on this premises farm specific, under joint ownership and it remains on this premises, or under joint ownership and used on other farm premises? A list
of equipment follows.
1. Company vehicles/trailers:
Farm specific?
Yes
No
2. Feed trucks (excess feed):
Farm specific?
Yes
No
If No, by whom is equipment jointly used:
If No, by whom is equipment jointly used:
______________________________________________________________
______________________________________________________________
Dates: ____________________________________
Dates: ____________________________________
3. Gates/panels:
Farm specific?
If No, by whom is equipment jointly used:
Yes
No
______________________________________________________________
Dates: ____________________________________
4. Lawn mowers:
Farm specific?
If No, by whom is equipment jointly used:
Yes
No
______________________________________________________________
Dates: ____________________________________
5. Live haul loaders:
Farm specific?
If No, by whom is equipment jointly used:
Yes
No
6. Poult trailers:
Farm specific?
If No, by whom is equipment jointly used:
Yes
No
______________________________________________________________
______________________________________________________________
Dates: ____________________________________
Dates: ____________________________________
7. Pre-loaders:
Farm specific?
If No, by whom is equipment jointly used:
Yes
No
______________________________________________________________
Dates: ____________________________________
8. Pressure sprayers/washers: Farm specific?
If No, by whom is equipment jointly used:
Yes
No
______________________________________________________________
Dates: ____________________________________
Describe pre-loader cleaning and disinfection procedures: __________________
__________________________________________________________________
9. Skid-steer loaders:
Farm specific?
If No, by whom is equipment jointly used:
Yes
No
______________________________________________________________
Dates: ____________________________________
10. Tillers:
Farm specific?
If No, by whom is equipment jointly used:
Yes
No
______________________________________________________________
Dates: ____________________________________
11. Trucks:
Farm specific?
If No, by whom is equipment jointly used:
Yes
No
12. Other equipment
Farm specific?
If No, by whom is equipment jointly used:
Yes
No
______________________________________________________________
______________________________________________________________
Dates: ____________________________________
Dates: ____________________________________
G. LITTER HANDLING
1. Litter type:
2. Supplier/source:
3. Is a litter shed present?
Yes
4. Do you do partial cleanouts?
Yes
No
If Yes, give dates of last partial cleanout: ___________________________________
6. Who does the cleanout?
Grower
Contractor
If contractor, name and location_______________________________________
VS Form 17-5
APR 2015
No
5. Date of last cleanout:
_______________________ date
Frequency of cleanout:
7. Litter is disposed of:
_______________________ times/month
On farm
Taken off-site
If taken offsite, name and location: ________________________________________
Page 3 of 5
H. DEAD BIRD DISPOSAL
2. How is daily mortality handled?
1. Approximate normal daily mortality
a. On-farm: Burial pit/incinerator/composted/other (specify:_____________________________________)
_____________ Number of birds
b. Off-farm: Landfill/rendering/other (specify: ________________________________________________)
3. What is the pickup schedule?
c. Off-farm disposal performed by: Owner/employee/other (specify: ______________________________)
d. If burial or compost pits are used, are carcasses covered with soil on a daily basis?
4. Contact name of company or individual responsible for disposal (If rendering is
used, include location of carcass bin on the farm map.)
Yes
No
5. Does the carcass bin have a cover?
Yes
No
Is it routinely kept closed?
Yes
No
I. FARM VISITORS
1. How many visitors do you have on a daily basis?
2. Is there a visitor log to sign in?
Yes
No
_____________ Number
Is it current?
Yes
No
Yes
No
3. Do you provide any outer clothing to visitors entering the farm?
If Yes, identify items of clothing provided: _________________________________________________________________________________
4. Mark the following services that were on the farm when this flock was on the farm. List date of service and name of person (or contract company) and if they had contact
with the birds.
Service
Dates
Name
Contact?
Service person
Yes
No
Yes
No
Vaccination crew
Yes
No
Yes
No
Moving crew (moving from brood to
grow, or pullet house to layer house)
Yes
No
Yes
No
Processing plant load out
Yes
No
Yes
No
Load-out crew (positive flock)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
If load-out took more than 1 night, was the returning crew the same crew?
Truck Number/Numbers
Trailer Number/Numbers
What plant did flock go to?
Load-out crew
(flock previous to positive flock)
Yes
No
If load-out took more than 1 night, was the returning crew the same crew?
Truck Number/Numbers
Trailer Number/Numbers
What plant did flock go to?
Poult delivery
Yes
No
Yes
No
Rendering pickup
Yes
No
Yes
No
Litter services
Yes
No
Yes
No
Cleanout services
Yes
No
Yes
No
Equipment shared, rented, loaned,
borrowed (each of the categories of
visitor is likely to be accompanied by
equipment of some sort or another)
Yes
No
Yes
No
Feed delivery
Yes
No
Yes
No
5. Who makes sure covers are closed after delivery?
6. Are feed covers kept closed?
Yes
No
J. WILD BIRDS
1. Do you see wild birds around your farm?
Yes
No
If Yes, what type of birds? (check all that apply)
Waterfowl
2. Do you see birds all year round?
Yes
No
If Yes, what type of birds? ______________________________________________________
3. Is there seasonality to the presence of some types of birds?
Yes
No
If Yes, what type of birds and what seasons do you see them?
Gulls
Small perching birds (sparrows, starlings, or swallows)
___________________________________________________________________________
4. Where are wild birds seen in relation to the farm? (check all that apply)
Other water birds (egrets, cormorants, etc.)
On adjacent habitats away from facilities and equipment (identify location of habitat on photos)
Other _________________________________________
On the farm but not in the barns (identify facilities or equipment in which birds have contact)
On the farm and sometimes in the barns (identify facilities or equipment in which birds have
contact)
VS Form 17-5
APR 2015
Page 4 of 5
K. NARRATIVE/COMMENTS
FARM DIAGRAM - Attach a download from satellite imagery, if possible. In addition, draw a simple schematic map of the farm site centering with the poultry
houses/pens. Identify where the HPAI positive flocks were housed. Also include: fan banks on houses, residence, driveways, public roads, bodies of water, feed
tanks, gas tanks, out house buildings, waster dumpsters, electric meters, dead bird disposal, parking areas, and other poultry sites, etc. Digital photographs, if
allowed, are excellent supporting documentation.
VS Form 17-5
APR 2015
Page 5 of 5
| File Type | application/pdf |
| Author | Harris, Sheniqua M - APHIS |
| File Modified | 2015-04-23 |
| File Created | 2015-04-14 |