4c

REPORTING THE IDENTIFICATION OF A SELECT AGENT OR
TOXIN: FEDERAL LAW ENFORCEMENTSEIZURE REPORT
(APHIS/CDC FORM 4C)

FORM APPROVED
OMB NO. 0579-0213
OMB NO. 0920-0576
EXP DATE 11/30/2015

Read guidance instructions at http://www.selectagents.gov/CDForm.html before completing this form. Answer all items completely and
type or print in ink. The form must be signed and submitted to either APHIS or CDC by email attachment, fax, or mail:
Animal and Plant Health Inspection Service
Agricultural Select Agent Program
4700 River Road Unit 2, Mailstop 22, Cubicle 1A07
Riverdale, MD 20737
FAX: (301) 734-3652
E-mail: [email protected]

Centers for Disease Control and Prevention
Division of Select Agents and Toxins
1600 Clifton Road NE, Mailstop A46
Atlanta, GA 30333
FAX: (404) 471-8469
Email: [email protected]

Accession Number:

(For Program use ONLY)

Submit completed form only once by either email, fax, or mail
APHIS/CDC REFERENCE ID#: _________________________
SECTION A – FEDERAL LAW ENFORCEMENT INFORMATION
1. Name of federal law enforcement agency:

3.Telephone #:

2.Name of federal law enforcement agent:
First:
MI:
4.Fax #:

Last:

5.Email address:

SECTION B – SELECT AGENTS AND TOXINS SEIZED
1.Name of entity select agent or toxin seized from:
2.Select agent or toxin seized

3.Amount seized

4.Disposition of seized select agent or toxin

5. Were any of the seized select agents or toxins handled outside of primary containment which may have led to an unintentional release and/or exposure to the select
agent or toxin?
 No
 Yes (If Yes, you are required under 7 CFR Part 331.19, 9 CFR Part 121.19, and 42 CFR Part 73.19 to complete and submit an APHIS/CDC Form 3)
6.Comments / Notes:

I hereby certify that the information contained on this form is true and correct to the best of my knowledge. I understand that if I knowingly provide a false statement on any part of this form, or
its attachments, I may be subject to criminal fines and/or imprisonment. I further understand that violations of 7 CFR 331, 9 CFR 121, or 42 CFR 73 may result in civil or criminal penalties,
including imprisonment.
Signature of Agent: ___________________________________________________

Date Signed: _______________________________

Public reporting burden: Public reporting burden of providing this information 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. 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. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D74, Atlanta, Georgia 30333; ATTN: PRA (0920-0576).