Form APHIS-7077 Summary of Alleged Violations

 
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information unless it display a valid OMB control number. The valid OMB control number for this information collection is 0579-0056. 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 maintain the data needed, and completing and reviewing the collection of information.

United States Department of Agriculture
Animal and Plant Health Inspection Service
Animal Care

OMB Approved
0579-0056
Exp.: XX/XXXX

Horse Protection Inspection Field Notes
Event Information

1. Event name and location (city and State):
Inspection Information
3. Class Number:
4. Exhibition Number:

2. Horse Name:

6. Action Devices:
☐ Chains
Strikes coronet?
☐ Other (specify)
Over 6 ounces?
7. Metal Band Measurement
Right:
Left:
9. ☐ Flat shod ☐ Padded
Are the pads in compliance? ☐ Yes ☐ No
If no, explain:

5. Examination performed:
☐ Pre-show
☐ Post-show
☐ Place ____________

Horse Examination
Weight RIGHT leg device:
Weight LEFT leg device:
☐ Yes ☐ No
☐ Yes ☐ No
8. Heel/Toe Measurement
Left-heel:
Right-heel:
10. Prohibited substance observed?
If yes, explain:

Weighed by:

Right-toe:
Left-toe:
☐ Yes ☐ No

11. Is horse sore? ☐ Yes
☐ No
If yes, check all that apply: ☐ Bilateral sore ☐ Unilateral sore ☐ Scar rule violation ☐ Other ___________________________
12. Illustrate where horse is sore:

13. Additional signs of soreness observed (check all that apply):
☐ Consistent and repeatable pain response to digital
palpation, as illustrated in Block 11
☐ Clenching of abdominal muscles or tucking of the abdomen
☐ Head turning

☐ Altered stance (e.g., bucket stance)
☐ Increased respiratory rate
☐ Ears laid back
☐ Shifting of weight
☐ Other, as described below in Block #14

14. Additional evidence of scar rule violation observed
(check all that apply and illustrate in Block 11):
Posterior surfaces of pasterns:
☐ Bilateral areas of non-uniformly thickened epithelial tissue
☐ Proliferating granuloma tissue
☐ Irritation
☐ Moisture
☐ Edema
☐ Other evidence of inflammation (as described in Block 14)
15. Additional Information:

Anterior and anterior-lateral surfaces of the fore pasterns:
☐ Bilateral granulomas
☐ Other bilateral pathological evidence of inflammation (as described
below in Block 14)
☐ Other bilateral evidence of abuse indicative of soring, including, but not
limited to, excessive loss of hair (as described in Block 14)

16. Physical examination performed by USDA veterinarian(s) (sign and print name):

APHIS 7077
JUN 2016

Previous editions may be used.

17. Date and Time of Inspection: