VS 4-33 Brucellosis Test Record

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 0579-0047. The time required to complete this information collection is estimated to
average .17 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.

ALLtINCOMPLETEtRECORDS WILLtBEtRETURNED FORtCOMPLETION

STKTE

COOPERATIVEtSTATEyFEDERALt BRUCELLOSISt ERADICATION PROGRAMt

ZO/E

ZOUNTY

BRUCELLOSISt TESTt RECORD

PREMISESq I/qNUMBER

ROUTE-STREET-ROK/
STKTEq

REKSONqFORqTESTq

INITIKLq

Slaughter
Reaq

(

HdYqZertSq
Validationq

:q

LvstYq MktYq
Reaq

)

PostqMoveq
QuarYqTestq

y

SuspYq Ringq
Testq

Cq
U

N

PvtYq Saleq

YESq

NOYqINqHER/

Hq

SUMMKRY
NEGPq
KTIVEq

KINDtOFtHERDt
kEEFq

SWINEq

OTHERqESpecify below)

REKZP
TOR

/KTE Rec'd

TOTKL

MIXE/q

RTt– Retag
NAt–tNaturaltAdditiont
PA –tPurchased Additiont
AB – Aborter

RecordtALLt
Eartaggs(tandt
Tattoogs(

REK

FEEqkKSISq
(Federal)

SUS

VKZZq
TKTTOOq

KGEq kREED

RecordtALLt
Legiblet
Characters

PRIVKTE
(Owner’s
expense)

STKTEq
ZOUNTYq

IqZERTIFYQq
Thatq Iqhaveqdrawnq bloodq samplesqfromqeachqanimalqidentifiedqbelowq andq haveq
correctlyq listedqeachqtubeqnumberqwithqcorrespondingq identificationqnumberLqallq
numbersq andqlettersqofq allqeartagsq haveqbeenqlistedLqcattleqwithqexistingq
officialqeartagsqhaveqnotqbeenqretaggedLq andqwhenq paymentqisqclaimedqatq
programq expenseqinqaccordanceqwithqagreementq numberq belowLq noqpaymentq
hasq beenqorqwillqbeqreceived fromqanyq otherqsourceY
SIGNKTURE

KGREEqZO/E

ROUTEPSTREETPROK/

/KTEqkLE/

POSTqOFFIZEq

STKTEq

SEXq

ZIPqZO/E

REACTORS TAGGED AND BRANDED
/KTEQq
SIGNKTUREQq

LABORATORY RESULTS

kY Q
RECORDq KLL
IDENTIFICATIONq
NUMBERESD

TOTKL

SUSPq
PEZTq

DAIRYq

LKkORKTORY
PLKZE

/KTEqTESTED

VSqFORMqUPCCq
JUNE 2014

NOq

KreaqTestq

REMARKS

Wt

COMPLETEtHERDtTESTtOFtALLt
ELIGIBLEtANIMALSt

V

Otherq
(Iq
ESpecify belowDq

FE/ERKLq
EMPLOYEEq

ZIPqZO/E

GPSqZOOR/INKTES

RETEST

Epidemiologyq

VETqZO/E

ZERTIFIZKTIONqFORqPKYMENT

POSTq OFFIZEq

Diagnosticq

PREVIOUS
TESTq/KTE

H3R6MOWN3RM (LAST NAME, FIRST NAME, MI)

HER/qNUMkER

T UkEq
NUMBERq

OMBt APPROVED
0579-0047
EXP: XX/XXXX

RKPq kKPK CARD

FIELD TEST t
CODEt
Nt–tNegativet
Pt–tPositive

FPKq

CF

∆mP

OTHER

KGREEqZO/E

T EST q
INqP
T ERP

TEST INTERPRETATION
Classified By/Date

N - Negative
S - Suspect
R - Reactor

FIEL/qTESTq
/ONEqkYQ

By:_______________
Date:_____________

REMARKSq
KN/q
ADDITIONALq
INFORMATIONq

TESTt
AUTHORIZATIONt
EXPIRESt

REACTORq
TKGqNUMBERq

Privacy Act Notice
Veterinary Services – Brucellosis Information System and Brucellosis Recording and Reporting System
Authority: 21 U.S.C. 111, 112, 114, 114a-1, 115, 120, 121, 125, 134a-134f and title 9, Code of Federal Regulations, part 51 and
part 78.
Purpose and Routine Uses:
Routine uses of records maintained in the system, including categories of users and the purposes of such uses:
1)
2)
3)
4)
5)
6)
7)

Detecting the foci of infection to reduce the rate of spread of infection to new herds;
Evaluating brucellosis program activities of State, Federal, and contractual personnel;
Preparing mailing labels and preaddressed forms to enhance field activities;
Evaluating program effectiveness;
Detecting factors of epidemiologic importance in containing or eliminating foci of infected herds;
Assuring that brucellosis indemnities are promptly and properly paid;
Notification of livestock owners with the animals at high risk of exposure to brucellosis because of livestock movements or
an outbreak of disease or presence of quarantined premises in a community;
8) Referral to the appropriate agency, whether Federal, State, local, or foreign, charged with responsibility of investigating or
prosecuting a violation of law concerning animal disease control and eradication, or of enforcing or implementing a
statute, rule, regulation, or order issued pursuant thereto, of any record within this system when information available
indicates a violation or potential violation of law concerning animal disease control and eradication, whether civil, criminal,
or regulatory in nature, and either arising by general statute or particular program statute, or by rule, regulation, or court
order issued pursuant thereto;
9) Litigation by the Department of Justice when the agency, or any component thereof, or any employee of the agency in his
or her official capacity, or any employee of the agency in his or her individual capacity where the Department of Justice
has agreed to represent the employee, or the United States, where the agency determines that litigation is likely to affect
the agency or any of its components, is a party to litigation or has an interest in such litigation, and the use of such
records by the Department of Justice is deemed by the agency to be relevant and necessary to the litigation; provided,
however, that in each case, the agency determines that disclosure of the records to the Department of Justice is a use of
the information contained in the records that is compatible with the purpose for which the records were collected;
10) Use in a proceeding before a court or adjudicative body before which the agency is authorized to appear, when the
agency, or any component thereof, or any employee of the agency in his or her official capacity, or any employee of the
agency in his or her individual capacity where the agency has agreed to represent the employee, or the United States,
where the agency determines that litigation is likely to affect the agency or any of its components, is a party to litigation
or has an interest in such litigation, and the agency determines that use of such records is relevant and necessary to the
litigation; provided, however, that in each case, the agency determines that disclosure of the records to the court is a use
of the information contained in the records that is compatible with the purpose for which the records were collected; and
11) Response to a request from a congressional office from the record of an individual made at the request of that individual.
To certain Federal and State animal health officials to conduct, analyze, and report on the progress of animal disease
control or surveillance programs.

Disclosure: Furnishing this information is voluntary; however, failure to furnish this information may impede brucellosis
eradication activities.