APHIS 7087 Animal Welfare Complaint Worksheet

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to, a
collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection
is 0579-0036. The time required to complete this information collection is estimated to average .25 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
0579-0036
EXP: XX/XXXX

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
ANIMAL CARE

ANIMAL WELFARE COMPLAINT WORKSHEET
Complaint No.:

Date Entered:

Received By:

Referred To:

Reply Due:

Facility or Person Complaint Filed Against:
Name:

Customer No.:
License/Registration No.:

Mailing Address:

City:

State:

Zip Code:

Phone No.:

Complainant
Name:
Mailing Address:
City:

State:

Zip Code:

How was complaint received?
Details of Complaint:

Results:
Application Packet and Information Provided:

YES.

NO.

Inspector:

Date:

Reviewed By:

Date:

APHIS Form 7087
OCT 2018

Phone No.: