Form FDA 1995 Form FDA 1995 Physical Examination of Cows - Report

Form Approved: OMB No. 0910-0212
Expiration Date: July 31, 2018
See Reverse for OMB Statement

DEPARTMENT OF HEALTH AND HUMAN SERVICES
FOOD AND DRUG ADMINISTRATION

REPORT OF PHYSICAL EXAMINATION OF COWS
Required for Introduction into the United States of Milk and Cream under the Federal Import Milk Act
Owner

Date of examination

Address

Location of herd

ANIMAL
NO.

IDENTIFICATION OF ANIMAL
(Accurate description or ear tag number
or registration name and number)

AGE

GENERAL
CONDITION

*TEMPERATURE

*PULSE

COUGH

UDDER

SYMPTOMS
OF DISEASE

CONCLUSIONS
(Healthy or Unhealthy)

1
2
3
4
5
6
7
8
9
10
11
12

I HEREBY CERTIFY that I have made a physical examination of the

cows above described, with results as stated.
(Signed)

(Veterinary Degree)

(Official Connection)

(Address)

*Where temperature or pulse is higher than normal, but the animal is otherwise apparently normal, notation should be made as to the condition of exercise or excitement under which the
temperature and pulse were taken.
Milk or cream from unhealthy cows must be so disposed of as to prevent its introduction into the United States, and certificate of owner of cows, stating how such milk or cream will be disposed of,
must be given on the other side of this form.
Use additional forms if this space is insufficient for reporting all cows in herd.
(OVER)
PREVIOUS EDITION IS OBSOLETE.

FORM FDA 1995 (10/15)

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CERTIFICATE

I HEREBY CERTIFY that I am the owner of the cows described on the other side of this form; that no milk or cream from cows that are unhealthy, as shown on
this form, or from cows which have not had a physical examination, will be introduced into the United States; and that milk or cream from cows that are unhealthy,
as shown on this form, will be disposed of as follows:

(Signed)

(Date)

FORM FDA 1995 (10/15)

(Name of Owner)

(Address)