FIMA Form 1995

Form Approved: OMB No. 0910-0212
Expiration Date: June 30, 2012
See Reverse for OMB Statement

DEPARTMENT OF HEALTH AND HUMAN SERVICES
FOOD AND DRUG ADMINISTRATION

REPORT OF PHYSICAL EXAMINATION OF COWS
Required for Introduction into the United States of Milk and Cream under the Federal Import Milk Act
Owner

Date of examination

Address

Location of herd

ANIMAL
NO.

IDENTIFICATION OF ANIMAL
(Accurate description or ear tag number
or registration name and number)

AGE

GENERAL
CONDITION

*TEMPERATURE

*PULSE

COUGH

UDDER

SYMPTOMS
OF DISEASE

CONCLUSIONS
(Healthy or Unhealthy)

1
2
3
4
5
6
7
8
9
10
11
12

I HEREBY CERTIFY that I have made a physical examination of the

cows above described, with results as stated.
(Signed)

(Veterinary Degree)

(Official Connection)

(Address)

*Where temperature or pulse is higher than normal, but the animal is otherwise apparently normal, notation should be made as to the condition of exercise or excitement under which the
temperature and pulse were taken.
Milk or cream from unhealthy cows must be so disposed of as to prevent its introduction into the United States, and certificate of owner of cows, stating how such milk or cream will be disposed of,
must be given on the other side of this form.
Use additional forms if this space is insufficient for reporting all cows in herd.
(OVER)
PREVIOUS EDITION IS OBSOLETE.

FORM FDA 1995 (8/09)

PSC Graphics (301) 443-1090

EF

Public reporting burden for this collection of information is estimated to average .25 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden to:
Department of Health and Human Services
Food and Drug Administration
Office of Chief Information Officer (HFA-710)
5600 Fishers Lane
Rockville, MD 20857

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number.

CERTIFICATE

I HEREBY CERTIFY that I am the owner of the cows described on the other side of this form; that no milk or cream from cows that are unhealthy, as shown on
this form, or from cows which have not had a physical examination, will be introduced into the United States; and that milk or cream from cows that are unhealthy,
as shown on this form, will be disposed of as follows:

(Signed)

(Date)

FORM FDA 1995 (8/09)

(Name of Owner)

(Address)