NAMHS-403 NAHMS; Beef 2017 Study Consent Form

Form Approved
OMB Number: 0579-0326
Expires xxxx

UNITED STATES DEPARTMENT OF AGRICULTURE
N AHMS; BEEF 2017 STUDY CONSENT FORM
For release of information for:

(Consenting Operator: Hereafter referred to as YOU)
The USDA’s Animal and Plant Health Inspection Service’s (APHIS) National Animal Health
Monitoring System (NAHMS) is implementing a study of the beef industry i n 24 states. NAHMS
is a non-regulatory program. The purpose of the study is to develop statistics on animal health
issues.
To initiate the study, a sample was selected from the confidential list of operations maintained by
USDA, NASS. Your operation was selected for participation in the study.
By signing this Consent Form, you are agreeing to allow USDA, NASS staff to provide the following
information from this study to the State NAHMS Coordinator, who is employed by USDA, APHIS:
Your operation name, if applicable; your name; address; and telephone number.
The NAHMS coordinator will share this information with a veterinarian, who will contact you and
explain the next phase of the study.
Only those collecting the data know the identity of the respondent. No name or contact
Information will be associated with individual data, and no data will be reported in a way that could
reveal the identity of a participant. Data are presented only in an aggregate manner.
When you are contacted by a veterinarian and asked to participate in the next phase of the study,
you are free to accept or decline participation in the study at that time.

(Consenting Operator)

(Date)

(NASDA Field Enumerator/RFO Staff)

(Date)

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 0579-0326. The time required to complete this information collection is estimated to
average .17 hours per response, including the time for reviewing instructions, searching existing data resources,
gathering and maintaining the data needed, and completing and reviewing the collection of information.

NAHMS-403
AUG 2017