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
Date of examination
Location of herd
IDENTIFICATION OF ANIMAL
(Accurate description or ear tag number
or registration name and number)
(Healthy or Unhealthy)
I HEREBY CERTIFY that I have made a physical examination of the
cows above described, with results as stated.
*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.
PREVIOUS EDITION IS OBSOLETE.
FORM FDA 1995 (10/15)
PSC Publishing Services (301) 443-6740 EF
This section applies only to requirements of the Paperwork Reduction Act of 1995.
*DO NOT SEND YOUR COMPLETED FORM TO THE PRA STAFF EMAIL ADDRESS BELOW.*
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review instructions, search existing data sources, gather and maintain the data needed and complete and review the
collection of information. Send comments regarding this burden estimate or any other aspect of this information
collection, including suggestions for reducing this burden, to:
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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:
FORM FDA 1995 (10/15)
(Name of Owner)
|File Title||FORM FDA 1995|
|Subject||Report of Physical Examination of Cows|
|Author||PSC Publishing Services|