Information Collection

State, Local, or Tribal Government

IC 184526 under ICR 201611-0579-005 · OMB 0579-0101.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0579-0101 can be found here:

2025-02-10 - No material or nonsubstantive change to a currently approved collection
2024-10-10 - No material or nonsubstantive change to a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VS 5-18 State, Local, or Tribal Government	Form
VS 5-18 Record of Animals Moved VS 5-18 Dec 2011.pdf www.aphis.usda.gov/library/forms/pdf/vs5_18.pdf	Form
VS 5-19 FLOCK INSPECTION AND EPIDEMIOLOGY REPORT VS 5-19 DEC 2011.pdf	Form
VS 5-19 D Scrapie Epidemiology Report VS 5-19D Feb 2011.pdf	Form
VS 5-20 Individual Animal Information Report VS 5-20 DEC 2011.pdf	Form
VS 1-23 Appraisal and Indemnity Claim Form REV VS 1-23 Sep 2010.pdf	Form
VS 1-23 A Indemnity Worksheet - Owner/Company VS 1-23A-work May 2009.doc	Form
VS 5-19C Scrapie PEMMP Inspection Report VS 5-19C Feb 2011.pdf	Form
VS 5-29 Cooperative State - Scrapie Control Program VS 5-29 DEC 2011.pdf	Form
Vs 5-29A Scrapie Test Record - Continuation Sheet VS 5-29A DEC 2011.pdf	Form
VS 10-4 Specimen Submission VS 10-4 Aug 2009.doc www.aphis.usda.gov/library/forms/pdf/VS_Form10_4.pdf	Form
Vs 5-19A Flock Inspection and Epidemiology Report Initial Flcok I REV VS 5-19A June 2013 Final.pdf	Form
Vs 5-19b Flock Inspection and Epidemiology Report Flock Inspectio REV VS 5-19B June 2013 Final.pdf	Form
VS 5-24 Application for Scrapie Classification, Classification R VS 5-24 Apr 2010.doc	Form
VS 5-18A RECORD OF ANIMALS ACQUIRED VS 5-18A Dec 2011.pdf	Form
VS 1-27 PERMIT FOR MOVEMENT OF RESTRICTED ANIMALS VS 1-27 JUL 2011.doc www.aphis.usda.gov/library/forms	Form
VS 17-140 UNITED STATES ORIGIN HEALTH CERTIFICATE REV VS 17-140 NOV 2014.pdf www.aphis.usda.gov/library/forms	Form
VS 5-21 AGREEMENT TO CONDUCT THE OFFICIAL HISTOPATHOLOGY VS 5-21 DEC 2011.docx	Form
mou.pdf MOU	IC Document
How to Create an On-Line CVI for AV.ppt How to Create an On-Line CVI for AV	IC Document
Appendix A-1 FY 2010 Scrapie CA Guidance.docx Appendix A-1 FY 2010 Scrapie CA Guidance	IC Document
Appendix A-2 Coop Agreement Award ASI 10-9100-1231.pdf Appendix A-2 Coop Agreement Award ASI 10-9100-1231	IC Document
Appendix A-3 NIAAGrant.pdf Appendix A-3 NIAAGrant	IC Document
Appendix A-4_ MOU template for scrapie.doc Appendix A-4_ MOU template for scrapie	IC Document
Appendix B_10-4 and 5-29 worksheets.docx Appendix B_10-4 and 5-29 worksheets	IC Document
Appendices C-E screenshots.doc Appendices C-E screenshots	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

State, Local, or Tribal Government

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 9 CFR 54.2-54.21 and 79.2-79.6

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VS 5-18	Record of Animals Moved	VS 5-18 Dec 2011.pdf	http://www.aphis.usda.gov/library/forms/pdf/vs5_18.pdf	Yes	No	Printable Only
Form	VS 5-19	FLOCK INSPECTION AND EPIDEMIOLOGY REPORT	VS 5-19 DEC 2011.pdf		No		Paper Only
Form	VS 5-19 D	Scrapie Epidemiology Report	VS 5-19D Feb 2011.pdf		No		Paper Only
Form	VS 5-20	Individual Animal Information Report	VS 5-20 DEC 2011.pdf		No		Paper Only
Form	VS 1-23	Appraisal and Indemnity Claim Form	REV VS 1-23 Sep 2010.pdf		No		Paper Only
Form	VS 1-23 A	Indemnity Worksheet - Owner/Company	VS 1-23A-work May 2009.doc		No		Paper Only
Form	VS 5-19C	Scrapie PEMMP Inspection Report	VS 5-19C Feb 2011.pdf		No		Paper Only
Form	VS 5-29	Cooperative State - Scrapie Control Program	VS 5-29 DEC 2011.pdf		No		Paper Only
Form	Vs 5-29A	Scrapie Test Record - Continuation Sheet	VS 5-29A DEC 2011.pdf		No		Paper Only
Form	VS 10-4	Specimen Submission	VS 10-4 Aug 2009.doc	http://www.aphis.usda.gov/library/forms/pdf/VS_Form10_4.pdf	Yes	No	Printable Only
Form	Vs 5-19A	Flock Inspection and Epidemiology Report Initial Flcok Inspection for Complete Monitored Status in Scrapie Flock Certification Program	REV VS 5-19A June 2013 Final.pdf		No		Paper Only
Form	Vs 5-19b	Flock Inspection and Epidemiology Report Flock Inspection for Complete Monitored Status in the Scrapie Flock Certification Program	REV VS 5-19B June 2013 Final.pdf		No		Paper Only
Form	VS 5-24	Application for Scrapie Classification, Classification Renewal, or Reclassification of a State	VS 5-24 Apr 2010.doc		No		Paper Only
Form	VS 5-18A	RECORD OF ANIMALS ACQUIRED	VS 5-18A Dec 2011.pdf		No		Paper Only
Form	VS 1-27	PERMIT FOR MOVEMENT OF RESTRICTED ANIMALS	VS 1-27 JUL 2011.doc	http://www.aphis.usda.gov/library/forms	Yes	No	Printable Only
Form	VS 17-140	UNITED STATES ORIGIN HEALTH CERTIFICATE	REV VS 17-140 NOV 2014.pdf	http://www.aphis.usda.gov/library/forms	Yes	No	Printable Only
Form	VS 5-21	AGREEMENT TO CONDUCT THE OFFICIAL HISTOPATHOLOGY	VS 5-21 DEC 2011.docx		No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Natural Resources

Subfunction: Agricultural Innovation and Services

Privacy Act System of Records

Title: Animal Health Surveillance and Monitoring System

FR Citation: 76 FR 228

Number of Respondents: 66

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 25 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	990	990
Annual IC Time Burden (Hours)	62,539	62,539
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
MOU	mou.pdf	11/07/2012
How to Create an On-Line CVI for AV	How to Create an On-Line CVI for AV.ppt	11/15/2012
Appendix A-1 FY 2010 Scrapie CA Guidance	Appendix A-1 FY 2010 Scrapie CA Guidance.docx	11/15/2012
Appendix A-2 Coop Agreement Award ASI 10-9100-1231	Appendix A-2 Coop Agreement Award ASI 10-9100-1231.pdf	11/15/2012
Appendix A-3 NIAAGrant	Appendix A-3 NIAAGrant.pdf	11/15/2012
Appendix A-4_ MOU template for scrapie	Appendix A-4_ MOU template for scrapie.doc	11/15/2012
Appendix B_10-4 and 5-29 worksheets	Appendix B_10-4 and 5-29 worksheets.docx	11/15/2012
Appendices C-E screenshots	Appendices C-E screenshots.doc	11/15/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.