VS 4-28 Application for Herd Entry/Renewal into the VBJDCP

INSTRUCTIONS ON REVERSE

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 number for this collection is 0579-0338. The time required to complete this information collection is estimated to average .250 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 0579-0338 EXP XX/XXXX

UNITED STATES DEPARTMENT OF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECTION SERVICE VETERINARY SERVICES			APPLICATION FOR HERD ENTRY/RENEWAL INTO THE VOLUNTARY BOVINE JOHNE’S DISEASE CONTROL PROGRAM
FARM NAME:			FARM ADDRESS:
OWNER/MANAGER NAME:					PHONE NUMBER:
FARM/PREMISES ID NUMBER:			VETERINARIAN’S NAME:
I wish to enroll my herd as in the Johne’s Program (JP): Management JP Level 1 JP Level 2 JP Level 3 JP Level 4 JP Level 5 JP Level 6
Testing Type Performed:	My herd was tested on:	Number tested:		Number of test positive results:		Number of test eligible animals in herd (3 years of age and older):
This Application is for: Enrollment Advancement Monitoring Please attach a copy of the relevant laboratory results and a copy of your herd management plan with this application.
I am willing to have my herd listed in the public register of herds, attaining or maintaining the indicated program level for the indicated cattle type. I understand that public registration may include listing on a web-site, printed material, and other forms of media. Yes No
Cattle Type: Dairy Beef Mixed Breed
A copy of the Voluntary Bovine Johne’s Disease Control Program producer Guidelines has been supplied to me and I agree to comply with the program guidelines. I certify that, to the best of my knowledge, all the information provided on this form is accurate.
Owner/Manager Signature:							Date:

VS FORM 4-28

APR 2010

INSTRUCTIONS FOR APPLICATION FOR HERD ENTRY/RENEWAL INTO THE VOLUNTARY BOVINE JOHNE’S DISEASE CONTROL PROGRAM

The major objective is to provide uniformity in recording official applications for Herd Entry/Renewal into the program, and to facilitate the recording of statistical information so that it will be readily available for program evaluation.

Farm Name –The last name, first name, and middle initial should be printed or legibly written.

Farm Address – Complete farm address. Include the mailing address if it is different from the farm address.

Owner/Manager Name – The owner/manager’s last name, first name, and middle initial should be printed or legibly written.

Phone Number – The number where the owner/manager can be reached.

Farm/Premises ID Number – The code number for the Herd, Farm, Ranch, Dairy, or premises ID is to be recorded in this block by the States that are maintaining a master identification file.

Veterinarian’s Name – Name of licensed veterinarian employed by the owner to assist in maintaining animal(s) health.

JOHNE’S DISEASE PROGRAM (JP) LEVELS

Management – Check this box if the herd owner has completed a risk assessment and a herd management plan but does not wish to be classified as a test positive or test negative herd.

JP Level 1 – Check this box if the herd owner has completed a risk assessment and a herd management plan and the herd is tested with an approved test strategy for Level 1 and the herd or any animals were not classified as infected.

JP Level 2 – Check this box if the herd owner has completed risk assessment and a herd management plan and the herd is tested with an approved test strategy for Level 2 and the herd or any animals were not classified as infected.

JP Level 3 - Check this box if the herd owner has completed a risk assessment and a herd management plan and the herd is tested with an approved test strategy for Level 3 and the herd or any animals were not classified as infected.

JP Level 4 - Check this box if the herd owner has completed risk assessment and a herd management plan and the herd is tested with an approved test strategy for Level 4 and the herd or any animals were not classified as infected.

JP Level 5 - Check this box if the herd owner has completed risk assessment and a herd management plan and the herd is tested with an approved test strategy for Level 5 and the herd or any animals were not classified as infected.

JP Level 6 - Check this box if the herd owner has completed risk assessment and a herd management plan and the herd is tested with an approved test strategy for Level 6 and the herd or any animals were not classified as infected.

Testing Type performed-Write in the type of testing (serum ELISA, fecal culture, environmental, fecal pooling, etc.) that was done if JP Level 1-4 or JP Level A-D, is being sought.

Herd Test Results-Tested: This space is provided to show the date the test was completed, number of animals tested and the number of animals that tested positive for Johne’s Disease.

Type of Application for Herd Entry: Enrollment, Advancement, and Monitoring Enrollment – Check this box if this is the initial entry into the program. Advancement – Check this box if the farm is advancing from one level to the next. Monitoring – Check this box if the farm is maintaining its current level.

If the laboratory results and herd management plan have not already been submitted, attach the laboratory results and herd management plan with this form.

Publicity Statement: Check “Yes”, if the farm is willing for the State to list the farm in any public list of Johne’s program herds. Checking “No” or not checking any box will be counted as the producer does not wish his/her farm to be posted in any public list.

Cattle Type - This space is provided to show on the charts whether the herd is of Dairy, Beef, or Mixed Breed, plus space is provided to record the breed of the animals.

Signature - Certify that all information provided is accurate and correct to the best of your knowledge.

THE VETERINARIAN SHOULD TRANSMIT ALL RECORDS TO THE CENTRAL OFFICE AS SOON AS POSSIBLE

VS FORM 4-28 (REVERSE)

APR 2010