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U.S. DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES
1. SFCP PARTICIPANT
Yes
FLOCK INSPECTION AND EPIDEMIOLOGY REPORT
Applicant
4. FLOCK LOCATION (If different from Item 3.)
Telephone Number
GPS NO.
(
)
9. FLOCK TOWNSHIP
10. RANGE
2. INSPECTION DATE
No
3. OWNER NAME/CONTACT, ADDRESS AND TELEPHONE NO. (Include Zip Code)
5. INSPECTOR'S/VMO'S NAME
OMB APPROVED
0579-0101
EXP DATE XX/XXXX
6. INSPECTOR'S ID
7. FLOCK ID
8. FLOCK COUNTY
11. SECTION
12. LATITUDE
13. LONGITUDE
14. REASON FOR INSPECTION (Please check all that apply)
Routine
High Risk Animals
Exposed Animals
15. FLOCK STATUS (Please check all that apply)
Certified
Enrolled
Select
Other (Please Specify)
Clinically Suspicious
Source
Exposed
Plan
Invest
Infected
Other (Please Specify)
P Plan
16. FLOCK TYPE (Please check one box)
Purebred
Commercial Breeder
Feeder
Other (Please Specify)
17. FLOCK INVENTORY
Males > 1 Yr.
Males < 1 Yr.
Castrated Males < 1 Yr.
Females > 1 Yr.
Females < 1 Yr.
Other (Please Specify)
18. VETERINARY PRACTITIONER'S NAME
Total
19. PRACTITIONER'S ID
21. PREDOMINANT BREED(S)
20. SPECIES
Ovine
Caprine
22. FLOCK HISTORY AND REMARKS (Attach additional sheets, if needed.)
23. FLOCK IDENTIFIED THROUGH ANIMAL MOVEMENT (List name, location, reason, and known dates for each. Attach additional shee ts, if needed. For each positive and exposed animal which has
moved from the flock, complete and attach VS Form 5-20.)
Name
Address
City
State
Reason (Circle One)
Zip Code
A.
Date
Origin of Positive
Disposition, High Risk
Disposition, Exposed
B.
Origin of Positive
Disposition, High Risk
Disposition, Exposed
C.
Origin of Positive
Disposition, High Risk
Disposition, Exposed
D.
Origin of Positive
Disposition, High Risk
Disposition, Exposed
E.
Origin of Positive
Disposition, High Risk
Disposition, Exposed
24. FLOCK OWNER'S SIGNATURE
27. INSPECTOR'S/VMO' S SIGNATURE
25. HAVE YOUR EWES HAD DIRECT CONTACT (fence to fence or direct
mixing) WITH NO PROGRAM SHEEP OR SHEEP WITH A
LATER STATUS DATE SINCE LAST INSPECTION (SEE REMARKS)
Yes
No
N/A
STATUS DATE OF EWES ONLY (if checked yes)
26. HAVE ANY OF YOUR SHEEP BEEN ON
PREMISES OR PASTURES NOT LISTED ON
PREVIOUS REPORTS
Yes
No
N/A
30. SFCP STANDARDS
Meeting Standards
28. CONDITION OF ANIMALS
All Clinically Normal
Clinically Suspicious Animals Seen
VS FORM 5-19
DEC 2011
29. HAVE RAMS OF LOWER PROGRAM STATUS BEEN INTRODUCED INTO
THE FLOCK
YES
NO
N/ A
STATUS DATE OF RAMS ONLY (if checked yes)
(Previous editions are obsolete.)
Not Meeting Standards (explain in #22 )
Not Applicable
File Type | application/pdf |
File Title | InForms - vs5-19.wpf |
Author | kastratchko |
File Modified | 2011-12-13 |
File Created | 2008-04-09 |