VS 17-141 Health Certificate for the Export of Live Finfish, Mollu

OMB APPROVED
0579-0020
EXP: XX/XXXX

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 for this information collection is 0579-0020. The time required to complete this information collection is estimated to average .5 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.

United States Department of Agriculture
Animal and Plant Health Inspection Services
Veterinary Services
(USDA/APHIS/VS)

Department of Commerce
National Oceanic and Atmospheric Administration
National Marine Fisheries Service
(DOC/NOAA-Fisheries)

Department of Interior
US Fish and Wildlife Service
(DOI/USFWS)

HEALTH CERTIFICATE FOR THE EXPORT OF LIVE FINFISH, MOLLUSKS, AND CRUSTACEANS
(AND THEIR GAMETES)
PART 1 OF 2
CERTIFICATE NUMBER

NOTE: Mark all the relevant items with (X) in the appropriate space.

I. Identification
Farmed/Aquaculture Stocks
Adult

Juvenile

Public resource/Wild/Feral Stocks

Larvae

Male Gametes

1. Genus/species (Latin Name):
2. Age (years):

Unfertilized eggs

Fertilized eggs

(Common Name):
Unknown

3. Total Net Weight (kg): (if known)

0-1

>1

Number (X1000):

Brood
Lot Identification:

Number of Containers in Consignment:

II. Place of Origin
1.
3.

2. Zone/Compartment:

Country/State:

Aquaculture Establishment (Name and Address and Map Coordinates or GPS if known):

III. Destination
1. Country/State:
3.

2. Zone/Compartment:

Aquaculture Establishment (Name and Address and Map Coordinates or GPS if known):

IV. Declarations
The undersigning representatives of the US Competent Authority attest that:
Zone/Compartment
All samples from the present consignment used in determining the health status of the
Country
Aquaculture establishment
were collected and tested in accordance with the procedures described in the
OIE Diagnostic Manual for Aquatic Animal Diseases (current ed.), or
USFWS/American Fisheries Society-Fish Health Section Standard Procedures for Aquatic Animal Health Inspections (AFS "Blue Book", current ed.), with negative results
Country
The Competent Authority certifies that live aquatic animals or their gametes in the present consignment have as their place of production a
Zone/Compartment
Aquaculture establishment that has been subjected to an official health surveillance scheme according to the procedures described in th e
USFWS/American Fisheries Society-Fish Health Section Standard
OIE Diagnostic Manual for Aquatic Animal Diseases (current ed.), or
Procedures for Aquatic Animal Health Inspections (AFS "Blue Book", current ed.), and which is officially recognized as being free from the pathogens or diseases
listed in the applicable table on thereverse side.

ONLY ONE ENDORSEMENT IS NEEDED. STAMP APPLICABLE BOX BELOW AND CROSS OUT/INITIAL NON-APPLICABLE BOXES.
USDA/APHIS/VS *
(Farm raised aquatic livestock)

DOI/USFWS
(Freshwater public resource/feral aquatic animals)

Accredited or Federal Veterinarian:

Approved Aquatic Animal Inspector:

Name (print):

Name (print)

Signature

Date

Endorsing Area Veterinarian in Charge:

Signature:

DOC/NOAA-Fisheries
(Marine wildlife/feral aquatic animals, and aquatic
animals in the Exclusive Economic Zone)
Approved Aquatic Animal Inspector:
Name (print):

Date:

Signature:

Date::

Address:

Address:

Federal veterinarian (if applicable)

Federal Veterinarian (if applicable)

Name (print)

Name (print)

Name (print):
Address:

Signature:

Date:

Stamp of Competent Authority:

VS FORM 17-141
(MAR 2006)

Signature:

Date:

Stamp of Competent Authority:

Signature:

Date:

Stamp of Competent Authority:

* USDA/APHIS/VS may, on request by DOI or DOC, endorse health certificates for non-farm raised aquatic animals
ANY ADDITIONAL INFORMATION OR SPECIFIC REQUIREMENTS OF IMPORTING COUNTRIES MAY BE ATTACHED TO THIS FORM
IN AN ADDENDUM

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 for this information collection is 0579-0020. 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.

CERTIFICATE NUMBER:

HEALTH CERTIFICATE FOR THE EXPORT OF LIVE FINFISH, MOLLUSKS, AND
CRUSTACEANS (AND THEIR GAMETES)
PART 2 OF 2
EXPORT OF LIVE FINFISH AND GAMETES
Freedom from the diseases/pathogens listed below has been
established for the areas denoted on the right

Country
Yes

Zone
No

Yes

Aquaculture Establishment
No

Yes

No

Epizootic hematopoietic necrosis/EHNV
Infectious hematopoietic necrosis/IHNV
Infectious pancreatic necrosis/IPNV
Infectious salmon anemia/ISAV
Oncorhynchus masou virus disease/OMV
Viral hemorrhagic septicemia/VHSV
And any of the following if required by the importing zone
Spring viremia of carp/SVCV

EXPORT OF LIVE MOLLUSKS AND GAMETES
Freedom from the diseases/pathogens listed below has been
established for the areas denoted on the right

Country
Yes

Zone
No

Yes

Aquaculture Establishment
No

Yes

No

Bonamiosis (Bonamia ostreae, B. exitiosa)
Haplosporidiosis (Haplosporidium costale, H. nelsoni)
Marteiliosis (Marteilia refringens, M. sydney)
Mikrocytosis (Mikrocytos mackini, M. roughleyi)
Perkinsosis

(Perkinsus marinus, P. olseni

And any of the following if required by the importing zone

EXPORT OF LIVE CRUSTACEANS AND GAMETES
Freedom from the diseases/pathogens listed below has been
established for the areas denoted on the right

Country
Yes

Taura syndrome/TSV
White spot disease/WSSV
Yellowhead disease/YHV
And any of the following if required by the importing zone

VS 17-141
(MAR 2006)

Zone
No

Yes

Aquaculture Establishment
No

Yes

No

INSTRUCTIONS FOR FORM VS 17-141 Part 1: HEALTH CERTIFICATE FOR THE EXPORT OF
LIVE FINFISH, MOLLUSKS AND CRUSTACEANS (AND THEIR GAMETES)
VS 17-141 is a model export form for the export of live aquatic animals or game tes that may be electively used by US producers. Under an arrangement among the 3
co-Competent Authorities for aquatic animals, APHIS may, when requested by USFWS or NOAA-Fisheries, endorse form VS 17-141 for animals under those Agencies'
jurisdictions. However, only APHIS may endorse health certificates for exported farmed aquatic animals, excluding any originating from the Executive Economic Zone ( EE)Z.
Requests from USFWS or NOAA-Fisheries for APHIS endorsement of VS 17-141 shoul d be directed to the applicable VS Area Office. USFWS or NOAA-Fisheries seekin g
APHIS endorsement must submit certificates signed by a Federal veterinarian in order for such certificates to be endorsed by APHIS.
STEP-BY-STEP INSTRUCTIONS ARE INCLUDED FOR FILLING OUT VS 17-141 BELOW, CORRESPONDING TO THE SECTIONS IN THE FORM.

1. CERTIFICATE NUMBER: This should go in the box provided. If USFWS or NOAA-Fisheries is requesting APHIS endorsement and has already
assigned a number, VS should still assign its own certificate number.
2. IDENTIFICATION: On the first line, the producer or submitter should mark whether the consignment is of farmed or non-farmed (public
resource/wild/feral stocks) origin. A single consignment would not typically be expected to contain both types of aquatic animals; but if it did,
additional VS 17-141 (part 1 and part 2) certificates or addenda may be used as needed.
a. On the second line, the producer or submitter should mark the appropriate boxes designating lifestage. If more than one lifestage is being
shipped in the same consignment, mark all relevant boxes.
b. On the third line, if more than one species is being consigned, their names may be attached as an addendum or listed on additional VS 17-141
forms.
c. On the fourth line, the producer or submitter should mark the box corresponding to the age of aquatic animals in the shipment, if known. If
broodstock of any age are being shipped, they can be so designated in this section.
d. On the fifth line, the net weight (exclusive of container weight) should be listed by the producer or submitter, as well as the total number of aquatic
animals/gametes in the consignment, regardless of the number of species being shipped. The Lot Identification block refers specifically to the
consignment being exported and should contain the unique identifying code for this consignment. Identifiers may consist of a production code or
any other designation that can facilitate tracking should the need arise later. The number of individual containers making up the total shipment
should also be noted by the producer or submitter.
3. PLACE OR ORIGIN: This section refers to the country, state and production facility from which the aquatic animals in the consignment are being
shipped. (Currently the US has no designated aquatic animal zones or compartment, but once those have been established, they may be
referenced.) Global Positioning Satellite coordinates may be supplied if known.
4. DESTINATION: This sections refers to the receiving areas for the consignment. Many other countries have existing zones or compartments,
which should be identifed when known by the producer or submitter. Global Positioning Satelite coordinates may be supplied if known.
5. DECLARATIONS: a. Attestations: The first part of this section deals with attestations (statements) from the submitting person, who must be
designated by his or her respective agency as an authorized representative. For APHIS, this can be an accredited veterinarian (accredited in the
state from which the animals originate), or a federal or state veterinarian. For certificates submitted to USFWS or NOAA-Fisheries for
endorsement, the submitter should be an Approved Aquatic Animal Inspector as officially designated by those agencies.
The health status of the US, or of any future-designated zones or compartments, has not yet been established for most applications of aquatic animal
export certification. However, individual production facilities (aquaculture establishments) may demonstrate evidence of disease freedom as stipulated
under the World Organization for Animal Health (OIE) or US Fish and Wildlife Service's AFS-FHS (Blue Book) certification schemes. OIE information
may be found at http:/www.oie.inat/eng/normes/fcode/A_summry.htm.
The relevant submission and testing protocol utilized for the consignment should be checked in this section. Only one protocol per certificate may be
selected by the submitter. For OIE purposes, original testing results from an APHIS-USFWS-and or NOAA approved aquatic pathogen detection
laboratory (not exceeding 60 days prior to the endorsement date in age) should be provided by the submitter for endorsement purposes. The
laboratory report should indicate the personnel who collected and submitted the samples; the date of collection and submission to the laboratory; the
number of animal samples tested; the types of tissues used in testing; the specific pathogens or diseases assayed and specific tests used. Results
should meet the importing country's requirments.
b.Certifications: There are 3 endorsement boxes for the 3 agencies on VS 17-141, but only one endorsement per consignment is needed. The
certification statements in this section may only be filled out by the VS Area Office or by designated representatives of USFWS and NOAA-Fisheries.
The health status of individual US production facilities ('aquaculture establishments') may be certified so long as a continuous and minimum 2-year
health history, corresponding to the stipulations of the OIE Diagnostic Manual for Aquatic Animal Diseases or the American Fisheries Society/Fish
Health Section's Blue Book, has been provided to VS by the producer. Freedoms may be certified for individual diseases or pathogens as indicated by
the boxes checked on the reverse side of the certificate.
6. ENDORSEMENT: Only one of the three boxes on the certificate need be endorsed per consignment. Endorsing personnel, after determining that
the certificate is complete and accurate, including all necessary testing results, should endorse the certificate with a signature in relevant box , and
strike out/initial the other two boxes as Not Applicable. The embossing stamp should be applied over the shaded area of the endorsed box.

VS 17-141 part 2: The submitter should indicate the section (Finfish, Mollusks, Crustaceans) of this page for which laboratory testing results are being
supplied. Under the relevant section, individual pathogens and diseases for which freedom may be declared based on those results should be X-ed
in under the (Yes) column for the level of testing being provided. Currently there are no Country or Zone-level programs for the US, so those blocks
should be lined out, as a declaration of freedom may currently be provided on the Aquaculture Establishment level only. Depending on the species of
aquatic animal being exported, submitter should put an N/A in the (Yes) column for those diseases for which exported species are not known to be
susceptible.

This form is 2 pages and both pages are 5 parts; you must fill out both pages.
Page 1 is first and page 2 is behind the tagboard in the middle

HEALTH CERTIFICATE FOR THE EXPORT OF LIVE
FINFISH, MOLLUSKS, AND CRUSTACEANS
(and their Gametes)

VS 17-141
(MAR 2006)

USDA-APHIS