VS 9-6 Report of Salmonella Isolations to NPIP Official State A

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 of this information collection is 0579-0007. The time required to complete this information collection is estimated to average .5 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 0579-0007
This report is required by Regulations (9 CFR Part 145). Failure to report will hinder investigation of disease to determine origin of the infection.
UNITED STATES DEPARTMENT OF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECTION SERVICE NATIONAL POULTRY IMPROVEMENT PLAN REPORT OF SALMONELLA ISOLATIONS TO NPIP OFFICIAL STATE AGENCIES (This report is issued as an aid to the detection of sources of Salmonella infections but does not imply responsibility or liability for the infection)
			1. LABORATORY ACCESSION NO.
2. NAME AND LOCATION OF STOCK
3. BREED, VARIETY, OR CROSS					4. INTENDED USE OF FLOCK Breeding Non-breeding
5. PERSON SUBMITTING SPECIMENS					6. DATE OF SUBMISSION
7. REPORTED HATCHERY SOURCE
SPECIMENS SUBMITTED
8. NO OF CHICKENS	9. NO. OF TURKEYS	10. NAME AND NO. OF OTHER SPECIES		11. APPROXIMATE AGE
12. ISOLATIONS Pullorum Typhoid Paralphold		13. SPECIFY OTHER SEROTYPE
14. REMARKS (Include any information which may aid in determining the source of infection)
15. NAME AND ADDRESS OF DIAGNOSTIC LABORATORY (Include ZIP Code)
16. REPORT SUBMITTED BY				17. DATE REPORT SUBMITTED
VS Form 9-6 MAY 2009

COPY DESIGNATIONS

PART 1 – LOCAL OFFICIAL STATE AGENCY

PART 2 – OFFICIAL STATE AGENCY

OF HATCHERY SOURCE

PART 3 – POULTRY IMPROVEMENT STAFF

APHIS, RIVERDALE, MD

PART 4 – LABORATORY COPY