VS 16-78 Report of Entry, Shipment of Restricted Imported Animal

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 OMB control numbers for this information collection are 0579-0245 and 0579-0040. The
time required to complete this information collection is estimated to average .16 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
0579-0245 and 0579-0040

1. CASE NUMBER:

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES
REPORT OF ENTRY AND SHIPMENT OF RESTRICTED
IMPORTED ANIMAL PRODUCTS OR BYPRODUCTS

2. CUSTOMS ENTRY NUMBER:

3. IMPORT PERMIT NUMBER (if applicable):

INSTRUCTIONS: Sections A-C to be completed by CBP Agriculture Specialists at the port of entry. Section D to be completed by the Approved Warehouse (AW). Sections E-F to be

completed by the Approved Establishment (AE) or Quarantine Facility (QF). Section G to be completed by Veterinary Services (VS).

CBP officers should fax or email a copy of the completed VS 16-78 form to the appropriate Service Center(s); send one copy to the AE or QF, and send the original form with the shipment

to the AW, AE, or QF.

A. REPORT OF ENTRY
4. DATE OF ARRIVAL:

5. PORT OF ENTRY:

6. COUNTRY OF ORIGIN:

7. VESSEL/FLIGHT NUMBER:

8. TOTAL QUANTITY RECEIVED (lb/kg):

9. TOTAL UNITS (specify unit type):

10. U.S. IMPORTER/HUNTER CONTACT INFORMATION:

11. SHIPMENT CONTAINS:
HUNTING TROPHIES
BOVINE SERUM
OTHER:

NAME:
U.S. ADDRESS:
PHONE:

EMAIL:

12. SPECIFY RESTRICTED MATERIAL (check all that apply in each column):
SPECIES
DISEASE(S) OF CONCERN
RUMINANT
SWINE
AVIAN
OTHER:

OTHER (continued):

TYPE(S) OF MATERIAL

FMD
ASF
ND/HPAI
OTHER:

BONES
HIDES/SKINS
BLOOD PRODUCTS
OTHER:
B. FACILITIES RECEIVING MATERIAL

13. APPROVED ESTABLISHMENT (AE) OR QUARANTINE FACILITY (QF):

13a. SERVICE CENTER RESPONSIBLE FOR AE OR QF:

NAME:

SC1

ADDRESS:

SC2

SC3

SC4

SC5

SC6

ADDRESS AND CONTACT INFORMATION:

PHONE NUMBER:
METHOD:

APPROVAL NUMBER:
14. APPROVED WAREHOUSE (AW):

N/A (shipment moving directly to AE or QF)

EMAIL

DATE NOTIFIED:

14a. SERVICE CENTER RESPONSIBLE FOR AW (if applicable):
SC1

NAME:

FAX

SC2

SC3

SC4

SC5

SC6

ADDRESS AND CONTACT INFORMATION:

ADDRESS:
PHONE NUMBER:

METHOD:

FAX

EMAIL

DATE NOTIFIED:

APPROVAL NUMBER:
C. REPORT OF MOVEMENT FROM PORT OF ENTRY
15. SHIPMENT SENT TO (check only one):
APPROVED ESTABLISHMENT (box 13)
16. QUANTITY SHIPPED (lb/kg):

QUARANTINE FACILITY (box 13)
17. UNITS SHIPPED (specify unit type):

APPROVED WAREHOUSE (box 14)

18. SEAL NUMBERS (if used):
19. SHIPMENT RELEASED TO:
IMPORTER/HUNTER (box 10)

BROKER
NAME:

OTHER
NAME:

PHONE NUMBER:

PHONE NUMBER:

EMAIL:

EMAIL:

NOTE: SHIPMENT WILL BE EXPECTED TO ARRIVE AT THE FACILITY LISTED IN BOX 15 WITHIN 10 DAYS OF ISSUANCE OF THIS FORM.
20. REMARKS:

21. DATE ISSUED:

22. ISSUING CBP SPECIALIST:

PORT NAME/CODE:

PRINT NAME:
VS FORM 16-78
AUG 2017

SIGNATURE:
Page 1 of 2

CASE NUMBER:

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES
REPORT OF ENTRY AND SHIPMENT OF RESTRICTED
IMPORTED ANIMAL PRODUCTS OR BYPRODUCTS

CUSTOMS ENTRY NUMBER:

IMPORT PERMIT NUMBER (if applicable):

D. REPORT OF RECEIPT BY APPROVED WAREHOUSE (AW) AND MOVEMENT TO APPROVED ESTABLISHMENT (AE)
24. WAS SHIPMENT COMPLETE AND INTACT? (i.e. did you receive everything listed in box 16 in undamaged condition? if no,
explain and include method of disinfection if required.)

23. DATE RECEIVED AT AW:

YES

NO

EXPLANATION (if needed):

N/A
27. METHOD OF SHIPMENT TO AE:

25. QUANTITY SHIPPED TO AE (lb/kg):

26. UNITS SHIPPED TO AE (specify unit type):

29. DATE VS NOTIFIED:

30. AUTHORIZED APPROVED WAREHOUSE (AW) REPRESENTATIVE:

28. DATE SHIPPED TO AE:

PRINT NAME:
METHOD:

FAX
EMAIL
MAIL
SIGNATURE:
E. REPORT OF RECEIPT BY APPROVED ESTABLISHMENT (AE) OR QUARANTINE FACILITY (QF)

31. DATE RECEIVED AT AE/QF:

32. WAS SHIPMENT COMPLETE AND INTACT? (i.e. did you receive everything listed in box 16 or box 25 in undamaged condition?
if no, explain and include method of disinfection if required.)
YES

NO

EXPLANATION (if needed):

33. AUTHORIZED AE OR QF REPRESENTATIVE RECEIVING SHIPMENT:

PRINT NAME:

SIGNATURE:

DATE:

F. REPORT OF TREATMENT AT APPROVED ESTABLISHMENT (AE)
34. MATERIAL TREATED:

35. DATE TREATMENT COMPLETED:

36. METHOD OF TREATMENT:

37. METHOD OF DISINFECTION AND DISPOSITION OF PACKAGES AND TRIMMINGS:

38.DATE VS NOTIFIED:

39. APPROVED ESTABLISHMENT (AE) INDIVIDUAL PERFORMING TREATMENT (or authorized representative):

PRINT NAME:
METHOD:

FAX
EMAIL
MAIL

SIGNATURE:
G. CLOSE OUT REPORT BY VETERINARY SERVICES (VS)

40. DATE COMPLETED REPORT OR NEGATIVE LAB RESULTS RECEIVED:
41. COMMENTS:

42. VS REPRESENTATIVE VERIFYING TREATMENT OR NEGATIVE LAB RESULTS:

PRINT NAME:
VS FORM 16-78
AUG 2017

SIGNATURE:
PAGE 2 0F 2

DATE: