NAHMS 332 Participant Agreement

Animal and Plant Health

Inspection Service

Veterinary Services

NAHMS Equine 2015

National Animal Health Monitoring System

2150 Centre Ave, Bldg B

Fort Collins, CO 80526

Form Approved

OMB Number 0579-0269

EXP. DATE: XX/20XX

Participant Agreement

The U.S. Department of Agriculture's Animal and Plant Health Inspection Service (APHIS),

the State of _______________, and the Participant hereby enter into this National Animal Health

Monitoring System (NAHMS) Equine 2015 study PARTICIPANT AGREEMENT, the terms of

which are set forth below.

1. APHIS and/or the State of __________________ will provide personnel who will be referred to as the Data Collector. The Data Collector and the Participant will participate together in implementing a statistically valid NAHMS study for determining national estimates of equine health practices and for compiling health information to enhance equine health and management. The Data Collector will complete one person-to-person interview with the Participant.

2. The Participant will assist APHIS by providing accurate information regarding equine health and management practices related to the study objectives. The Participant retains the right to refuse any questions deemed inappropriate.

3. The Data Collector will protect the origin of the data by recording the data with the Participant’s unique code number only. The Data Collector will not keep any key to the code after the completion of the study. The Data Collector and all other project personnel acknowledge that the Participant is providing information that he/she does not customarily share and is providing it with the expectation that it will not be made public. The one exception to this data protection is the suspicion or diagnosis of a dangerously contagious, infectious, or exotic disease foreign to the United States on the Participant’s premises (e.g., African horse sickness), in which case further investigation and possible action may occur.

4. Data collected by the Data Collector will not be used for regulatory purposes. However, information on a Participant’s animals revealed from sources unrelated to the Equine 2015 study, such as testing and inspection for movement or sale of animals, may cause regulatory action to be initiated by the State or APHIS.

5. APHIS may publish, or authorize others to publish, the aggregate (summary) findings acquired from NAHMS for the benefit of the equine industry, private industry, and other interested groups, but will ensure that the identity of the Participant is withheld. APHIS may not publish, or authorize others to publish, individual responses.

6. After completion of data reporting by the Participant, APHIS will provide the Participant with several reports containing summary results from all participating Participants. The Participant can obtain any further information available from this study by accessing the NAHMS Web site or subscribing to the NAHMS equine mailing list.

7. The Participant will complete a brief evaluation of the Equine 2015 study, the results of which will be used to assist APHIS in the design and implementation of future NAHMS surveys.

8. Any changes to or waivers of the terms of this PARTICIPANT AGREEMENT shall be binding on APHIS and the State of ___________________ and the Participant only if they are put in writing by each party.

9. The effective data collection period of this PARTICIPANT AGREEMENT shall begin with today’s date of _____/____/____ and end no later than December 31, 2015.

Continued on next page with biological testing.

/date /date

VS Employee, U. S. Department of Agriculture, APHIS Participant or authorized representative

OR _____________ Department of Agriculture

NAHMS-332

JUL 2014

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 0579-0269. The time required to complete this information collection is estimated to average .25 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collected.

I DO NOT

I AGREE TO AGREE TO

PARTICIPATE PARTICIPATE

10. (Participant’s initials needed in the appropriate column)

The Participant consents and authorizes the Data Collector

(a Federal or State veterinary medical officer or animal

health technician) to collect biologic samples or have

biosecurity assessment as follows:

1. A subset of the operations will have blood samples and fecal samples collected. Do you consent to participate in this testing if selected?

1. The blood samples will be collected from 1 to 20 equids per operation. The blood samples will be banked for future research. ____________ ____________

2. The fecal samples will be collected from 1 to 20 equines on the operation. Samples will be tested for Salmonella and E. coli antibiotic susceptibility. A Participant report will contain results for Salmonella and E. coli antibiotic susceptibility. ____________ ____________

2. A subset of the operations will have fecal samples collected for dewormer resistance testing. Do you consent to participate in this testing if selected? ____________ ____________

1. Samples will be collected from six equids pre- and post-administration of dewormer. The fecal samples will be evaluated for fecal egg counts and dewormer resistance will be determined by comparing pre- and post-deworming fecal egg counts. A Participant report will contain results of parasite testing and dewormer resistance evaluation.

3. A subset of the operations will have a tick exam performed and ticks collected for identification. Do you consent to participate in this testing if selected? ____________ ____________

1. From 1 to 10 equids per operation will be examined for the presence of ticks. If ticks are present the veterinary medical officer or animal health technician will collect a representative sample of ticks. Tick identification will be performed and a Participant report will contain results of tick identification.

4. A subset of operations will have a biosecurity assessment performed by the veterinary medical officer or animal health technician. Do you consent to participate in this assessment if selected? ____________ ____________

1. A biosecurity assessment form will be completed to evaluate operation biosecurity management practices. A Participant report will contain results of the biosecurity assessment.

(white copy given to NAHMS Coordinator, yellow copy left with Participant)