Form VS 9-2 VS 9-2 Flock Selecting and Testing Report

OMB Approved 0579-0007 and XXXX See reverse side for additional information.

Report No. O

United States Department of Agriculture Animal and Plant Health Inspection Service National Poultry Improvement Plan Flock Selecting and Testing Report

SUBPART ☐ B - Egg Type Chickens ☐ C - Meat Type Chickens ☐ D - Turkeys ☐ E - Waterfowl, Exhibition Poultry, Backyard Birds, and Game Birds ☐ F - Ostrich ☐ Other

CLASSIFICATION - U. S. ☐ Pullorum - Typhoid Clean ☐ M. Gallisepticum Clean ☐ M. Synoviae Clean ☐ Sanitation Monitored ☐ M. Meleagridis Clean ☐ Salmonella Enteritidis Clean

☐ Salmonella Monitored ☐ M.G. Monitored ☐ M.S. Monitored ☐ Avian Influenza Clean ☐ H5/H7 Avian Influenza Clean ☐ H5/H7 Avian Influenza Monitored ☐ Other

TYPE ☐ Primary ☐ Multiplier

1. Name and Address of Flock Owner (Include ZIP Code)

2. Location of Flock

3. Date of Preceding Test – This Location

4. Supply Flock for: (Name and Address of Hatchery or Dealer – include ZIP Code)

NPIP Approval Number

5. Breed, Variety, Strain, or Trade Name of Stock

Age of Birds

Code Identification

6. Males (Source and Number)

Date of Hatch

7. Females (Source and Number)

Date of Hatch

8. Total Birds in Flock

Blood Testing

a. Number of Males Tested

b. Number of Females Tested

c. TOTAL Number Tested

d. Number of Reactors

e. Number Sent to Laboratory

f. Laboratory Findings

9. PULLORUM TYPHOID

10. M. GALLISEPTICUM

11. M. SYNOVIAE

12. AVIAN INFLUENZA

13. OTHER (Specify)

AGREEMENT OF FLOCK OWNER I agree to keep my poultry breeding stock segregated from other poultry and in accordance with the provisions of the Plan and regulations of the official State Agency. I further agree to flock inspection by a representative of the official State Agency as prescribed by the provisions and regulations.

Signature of Inspector or Authorized Agent

Date

Signature of Flock Owner

Date

VS FORM 9-2 (JUL 2013) Previous edition may be used.

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

0579-0007 and 0579-XXXX. The time required to complete this information collection is estimated to average .16 – 4 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.

This report is required by regulation (9 CFR 145). Failure to report can result in OMB Approved

non-classification of poultry and poultry products under the NPIP. 0579-0007 and XXXX

United States Department of Agriculture

Animal and Plant Health Inspection Service

National Poultry Improvement Plan

Flock Selecting and Testing Report

Report NUMBERS From _________________________________________ TO ________________________________________

VS Form 9-2 (JUL 2013) Previous edition may be used.