Form 75.10A Application for Registration as an Importer of Nonhuman

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DEPARTMENT OF HEALTH & HUMAN SERVICES
PUBLIC HEALTH SERVICE
CENTERS FOR DISEASE CONTROL AND PREVENTION

NATIONAL CENTER FOR PREVENTION SERVICES

DIVISION OF QUARANTINE (EO3)

ATLANTA, GEORGIA 30333

Form
Approved
FORM
APPROVED
OMB
No.NO.
0920-0263
OMB
0920-0134
Expiration Date:
Date: 07/31/2015
9/30/2017
Expiration

APPLICATION FOR REGISTRATION AS AN IMPORTER OF NONHUMAN PRIMATES*
Organizational Name:

Telephone No.:

(

)

Address:

Person Responsible for Required Record Keeping and Reporting: (please print)

1. Estimated number of nonhuman primates to be Imported or to be received
within 31 days of importation in the period covered by this registration:
2. Number of nonhuman primates Imported or received
within 31 days of importation In the previous 2-year period*
3. Animal Holding Facilities:
a. Attach sketch of facility indicating rooms or area where newly acquired nonhuman primates are held

and the relationship of these rooms or areas to offices, laboratories and other animal rooms in the same building.

b. Air handling procedures in rooms or areas where newly acquired primates are held:

(1) Air pressure in holding rooms
(2) Is the incoming air filtered?

same asRr lower thanLn adjacent corridors and other immediately adjoining areas.

is higher than
No

Yes

If yes, specify the type of filtration:

(3) Is exhaust air filtered?

Yes

No

If yes, specify the type of filtration:

c. Usual number of animals per cage in the quarantine area:

Prosimians

Old World Species

New World Species

Great Apes

d. Waste disposal procedures for animal feces:

For dead animals:

4. Are newly acquired nonhuman primates held in rooms or areas separated from other animals? Yes
If yes, what is the usual length of the quarantine period?

No

days

5. Tuberculin-testing procedures:
a. Are newly acquired nonhuman primates routinely tuberculin-tested?

Yes

No

b. Is the quarantine period usually based on tuberculin-test results for the group as a whole?
If yes, the group must pass at least
c. Type tuberculin used: OT

PPD

d. Dose of tuberculin per test:

mg or

successive negative tests at

No

day intervals before release from quarantine.

TU

e. Route of tuberculin inoculation: intradermal

other

eyelid

abdomen

other

g. The tuberculin-test sites are routinely examined at 24 hours

48 hours

f. Site of tuberculin inoculation

Yes

CDC 75.10A, July 2012, CDC Adobe Acrobat X, S508 Electronic Version, July 2012

72 hours

post-inoculation. (Check all applicable time intervals)

* In accordance with Title 42, Code of Federal Regulations, Part 71, Subpart F, Section 71.53.
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6. Are animals that die during the initial period necropsied?

Yes

No
%.

If yes, estimated percentage of animals necropsied:

7. Is entry to the area where newly acquired nonhuman primates are held restricted to only those personnel who are essential to its operation?

9. Is a veterinarian retained to provide or supervise care of nonhuman primates?

Yes

Yes

No

No
Telephone No.

Name:
Address:

9. Personnel Health Program
a. Are all employees who work directly with nonhuman primates given a pre-employement physical?

Yes

No

b. Routine interval between periodic post-employment physical examinations of employees who work directly with nonhuman primates:

months

Not Done

Yes

c. Are all employees given a pre-employment tuberculin test?

No

d. Routine interval between tuberculin tests of employees after employment:

Months

Not Done

e. Are serum specimens from employees obtained and stored for reference diagnostic purposes?

Pre-employment: Yes

No

While employed: Yes

Interval between collection of reference sera while employed is:

f. Is a physician retained to supervise health care programs?

No

months.

Yes

No

Telephone No.

Name:

Address:

10. Assurance Statement

As a condition of registration I, (we) assure the Director, Centers for Disease Control and Prevention that I (we) will import live
nonhuman primates into the United States only for bona fide scientific, educational, or exhibition purposes. I (we) shall not
subsequently sell, resell, or otherwise distribute the nonhuman primates to any other person or organization without clear evidence
that these animals will be used solely for bona fide scientific, educational, or exhibition purposes. I (we) understand that "nonhuman
primates" are defined as all nonhuman primates of the Order Primates including but not limited to animals commonly known as
monkeys, chimpanzees, orangutans, gorillas, gibbons, apes, baboons, marmosets, tamarins, lemurs, and lorises.

11. Signature of Person Completing this Form

Date

Public reporting burden of this collection of information is estimated to average 10 minutes 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 D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-0263.
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CDC 75.10A, July 2012, CDC Adobe Acrobat X, S508 Electronic Version, July 2012

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