VS Form 9-21 Application For U.S. Avian Influenza Clean Compartment C

Clear Form
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 of this information collection is 0579-0007. The time required to complete this information collection is estimated to
average 40 hours 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.

OMB Approved
0579-0007
EXP: XX/XXXX

Application For U.S. Avian Influenza
Clean Compartment Component Registration

Instructions: Step 1: Applicants, please complete Sections A-E and certify application with signature on pg. 6. Step
2: Send the form to the OSA which completes Section F and signs. Step 3: OSA returns form to NPIP. Note: If you are
using Form B to comply with recertification requirements and none of the information in Sections A-E has changed
since initially applying, please complete only Section A and proceed to Step 2. Disclaimer: For initial Compartment
and Component registration, this form may be simultaneously submitted with Application Form A: Compartment
Registration for initial registration. However, Application Form B will not be reviewed until Application Form A has
been reviewed and approved.

A: Background Information. To be completed by company seeking certification.
To be considered for approval as a new component within a certified compartment, the following must
be completed.

Name of Company
Company Mailing Address
Name of Contact
Telephone Number
Alternate Telephone Number
Fax Number
Email Address
NPIP Classification

U.S. AI Clean 

U.S. H5/H7 AI Clean 

Breed/Type of Poultry
NPIP Classification Seeking
Compartment Mailing Address
Compartment Location (List States
Involved)
Name of Compartment
Anticipated Type of Components (F, M,
H, and E) to add within Compartment
Total Number of Components Seeking
Certification (sum of total numbers
listed in sections B-E below)

VS FORM 9-21
OCT 2018

Farm  Feedmill  Hatchery  Egg Depot 

Questionnaire.

To be completed by company seeking certification.

Please place a check mark by the answer that applies.
YES

NO

U.S. Avian Influenza Compartment Registration Form (Application Form A)
submitted. This form contains the components to be added within the new
compartment.
New facility within previously certified compartment.
Requalification of components within certified compartment due.
Components previously removed from certified compartment and now seeking
reinstatement within certified compartment.

B. Prerequisites for Farms (F).

To be completed by company seeking certification.

To be considered for approval as a component in a certified compartment, you must first provide the
following information.
Total number of farm premises seeking approval (Please list number). _____
List farm names (and associated NPIP numbers) seeking approval in box provided below. Separate farms
by use of a semicolon. Example: ChickaD, 13-3223: Hollow Oak 1, 12-1392; Hollow Oak 2, 12-1293. This
example includes three separate farms and three separate NPIP numbers.

Note: Supporting documents for Statements 1 and 2 below must be submitted with this application for
each farm. Please refer to the Compartmentalization for Protection Against Avian Influenza Disease in
Primary Poultry Breeding Companies in the United States of American; Specifications for Management
Procedures, Physical Requirements, and Protocols for verification of statement 3.
Farm Design, Physical Requirements, and Management Protocols
Statement 1: FMP 1: Site plan for each farm in the component which shows
characteristics of the component.
I hereby certify that I have attached to this application a site plan for each farm
seeking to be added as a component within the compartment.
Statement 2: FMP 2: Farm specifications, including fencing, signage, and
construction. (Note that farm specifications include the physical address of each
farm along with GPS coordinates.)

YES

NO

I hereby certify that I have attached to this application the applicable farm
specifications for each farm seeking to be added as a component within the
compartment.
Statement 3: FMP3-FMP13: Written documentation must be shown to the assigned
auditor on request.
I hereby certify that written documentation for each of the Farm
Management Protocols 3-13 is on file as accurate and complete to my knowledge
and will be provided to the assigned auditor on request.

C. Prerequisites for Feedmills (M). To be completed by the company seeking certification.
To be considered for approval as a component in a certified compartment, you must first provide the
following information.
Total number of feedmill premises seeking approval (Please list number). _____
List feedmill names seeking approval in box provided below. Separate feedmills by use of a semicolon.
Example: Feedmille 1; Jones & Parks; Willow Mill. This example includes three separate feedmills.

Note: Supporting documents for Statements 1 and 2 below must be submitted with this application for
each feedmill. Please refer to the Compartmentalization for Protection Against Avian Influenza Disease
in Primary Poultry Breeding Companies in the United States of American; Specifications for
Management Procedures, Physical Requirements, and Protocols for verification of statement 3.
Feedmill Design, Physical Requirements, and Management Protocols
Statement 1: FMMP 1: Site plan for each feedmill in the component which
shows characteristics of the component.
I hereby certify that I have attached to this application a site plan for each
feedmill seeking to be added as a component within the compartment.
Statement 2: FMMP 2: Feedmill specifications, including signage and construction.
(Note that feedmill specifications include the physical address of each feedmill along
with GPS coordinates.)
I hereby certify that I have attached to this application the applicable
feedmill specifications for each feedmill seeking to be added as a component
within the compartment.
Statement 3: FMMP3-FMMP9: Written documentation must be shown to the
assigned auditor on request.

YES

NO

I hereby certify that written documentation for each of the Feedmill Management
Protocols 3-9 is on file as accurate and complete to my knowledge and will
be provided to the assigned auditor on request.

D. Prerequisites for Hatcheries (H). To be completed by company seeking certification.
To be considered for approval as a component in a certified compartment, you must first provide the
following information.
Total number of hatchery premises seeking approval (Please list number). _____
List hatchery names (and associated NPIP numbers) seeking approval in box provided below. Separate
hatcheries by use of a semicolon. Example: Chickadee, Inc. -15-1425; Grandparent Line-65-1293. This
example includes two separate hatcheries with two separate NPIP numbers.

Note: Supporting documents for Statements 1 and 2 below must be submitted with this application for
each hatchery. Please refer to the Compartmentalization for Protection Against Avian Influenza
Disease in Primary Poultry Breeding Companies in the United States of American; Specifications for
Management Procedures, Physical Requirements, and Protocols for verification of statement 3.
Hatchery Design, Physical Requirements, and Management Protocols
Statement 1: HMP 1: Site plan for each hatchery in the component which
shows characteristics of the component.
I hereby certify that I have attached to this application a site plan for each
hatchery seeking to be added as a component within the compartment.
Statement 2: HMP 2: Hatchery specifications, including fencing, signage, and
construction. (Note that hatchery specifications include the physical address of each
hatchery along with GPS coordinates.)
I hereby certify that I have attached to this application the applicable hatchery
specifications for each hatchery seeking to be added as a component within
the compartment.
Statement 3: HMP3-HMP15: Written documentation must be shown to the assigned
auditor on request.
I hereby certify that written documentation for each of the Hatchery
Management Protocols 3-15 is on file as accurate and complete to my knowledge
and will be provided to the assigned auditor on request.

YES

NO

E. Prerequisites for Egg Depots (E).

To be completed by company seeking certification.

To be considered for approval as a component in a certified compartment, you must first provide the
following information.
Total number of egg depot premises seeking approval (Please list number). _____
List egg depot names seeking approval in box provided below. Separate egg depots by use of a
semicolon. Example: Clayton 1, 2, and 3; Heart Storage. This example includes two separate egg depots.

Note: Supporting documents for Statements 1 and 2 below must be submitted with this application for
each egg depot. Please refer to the Compartmentalization for Protection Against Avian Influenza
Disease in Primary Poultry Breeding Companies in the United States of American; Specifications for
Management Procedures, Physical Requirements, and Protocols for verification of statement 3.
Egg Depot Design, Physical Requirements, and Management Protocols
Statement 1: EDMP 1: Site plan for each hatchery in the component which
shows characteristics of the component.
I hereby certify that I have attached to this application a site plan for each egg
depot seeking to be added as a component within the compartment.
Statement 2: EDMP 2: Hatchery specifications, including fencing, signage, and
construction. (Note that egg depot specifications include the physical address of
each egg depot along with GPS coordinates.)
I hereby certify that I have attached to this application the applicable egg depot
specifications for each hatchery seeking to be added as a component within
the compartment.
Statement 3: EDMP3-EDMP12: Written documentation must be shown to the
assigned auditor on request.
I hereby certify that written documentation for each of the Egg Depot
Management Protocols 3-12 is on file as accurate and complete to my knowledge
and will be provided to the assigned auditor on request.

YES

NO

YES

NO

F. Verification. To be completed by each Official State Agency.
Please place a check mark by the answer that applies.

Is the company seeking certification in the U.S. H5/H7 Avian Influenza Clean
Compartment program a participant in good standing with the NPIP U.S. H5/H7
Avian Influenza Clean Program for Turkey Breeding Flocks?

Is the company seeking certification in the U.S. Avian Influenza Clean Compartment
program a participant in good standing with the NPIP U.S. Avian Influenza Clean
Program for Primary Egg-Type Chicken Breeding Flocks?
Is the company seeking certification in the U.S. Avian Influenza Clean Compartment
program a participant in good standing with the NPIP U.S. Avian Influenza Clean
Program for Primary Meat-Type Chicken Breeding Flocks?
Within the company, are all operations seeking certification as components within
the registered compartment in the U.S. Avian Influenza Clean Compartment
program (for egg- type chicken breeding flocks and meat-type chicken breeding
flocks) or the U.S. H5/H7 Avian Influenza Clean Compartment

CERTIFICATION OF OFFICIAL STATE AGENCY or AGENCIES
I DO HEREBY CERTIFY THAT ALL STATEMENTS MADE BY ME IN THIS APPLICATION ARE TRUE AND
CORRECT TO THE BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF. FURTHER, I UNDERSTAND THAT
IN THE EVENT I HAVE KNOWINGLY AND WILLFULLY MADE ANY FALSE STATEMENTS, I WILL BE LIABLE
FOR PUNISHMENT IN ACCORDANCE WITH ALL APPLICABLE LAWS AND STATUTES.
State:

State:

Signature:

Signature:

Date:

Date:

State:

State:

Signature:

Signature:

Date:

Date:

CERTIFICATION OF APPLICANT
I DO HEREBY CERTIFY THAT ALL STATEMENTS MADE BY ME IN THIS APPLICATION ARE TRUE AND
CORRECT TO THE BEST OF MY KNOWLEDGE, INFORMATION, AND BELIEF AND I HAVE OBTAINED ALL
NECESSARY OFFICIAL STATE AGENCIES' CERTIFICATION IN C ABOVE. FURTHER, I UNDERSTAND THAT IN
THE EVENT I HAVE KNOWINGLY AND WILLFULLY MADE ANY FALSE STATEMENTS, I WILL BE LIABLE FOR
PUNISHMENT IN ACCORDANCE WITH ALL APPLICABLE LAWS AND STATUTES.
Signature:
Date:

Application
A complete application must be sent to:
The National Poultry
Improvement Plan

1506 Klondike Road,
Suite 101
USDA-APHIS-VS
Conyers, GA 30094
[email protected] with
cc to [email protected]

For Department Use Only
Date
Received:

Reviewer:

Check Here if Registration Approval Granted: 
Check Here if Registration Approval Denied:



Signature:
For Components Denied, if Any, List Reasons:

Please note that registration approval for components does not mean the components are certified. Only
after an auditor’s review and successful passing can a component become certified.