VS 4-26 Vaccination Record - Long Form

OMB APPROVED
0579-0047
EXP: XX/XXXX

/ccordingMtoMtheMPaperworkMReductionM/ctMofMVKKGHManMagencyMmayMnotMconductMorMsponsorHMandMaMpersonMisMnotMrequiredMtoMrespondMtoHMaMcollectionMofMinformationMunlessMitMdisplaysMaMvalidMOM*McontrolMnumberDMTheM
valid OM*McontrolMnumberMforMthisMinformationMcollectionMis UGXKEUUFXDM TheMtimeMrequiredMtoMcompleteMthisMinformationMcollectionMis estimatedMtoMaverageMDULMhours perMresponseHMincludingMtheMtimeMforMreviewingM
instructionsHMsearchingMexistingMdataMsourcesHMgathering andMmaintainingMtheMdataMneededHMandMcompletingMandMreviewingMtheMcollectionMofMinformationDM

ALL VACCINATIONS MUST BE PROMPTLY REPORTED
COOPERATIVE STATE-FEDERAL BRUCELLOSIS ERADICATION PROGRAM

STATE

COUNTY

CODE

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES

BRUCELLOSIS VACCINATION RECORD

DOSAGE
FULLM

H3R6MNUM*3RM

H3R6MOWN3RM (LAST NAME, FIRST NAME, MI)

V/WWIN3MMFGM/N6MSTR/INM

PR3MIS3SM I6MNUM*3RM

ROUT3ESTR33TERO/6M

S3RI/LM NUM*3R/EXPIRATION DATE

KIN6MOFMH3R6M

POSTMOFFIW3M

R36UW36M

6/IRY

BEEF

ST/T3M

ZIPMWO63M

R3M/RKSM

GPSMWOOR6IN/T3SM
WVM /VM

NODM

/G3
I63NTIFIW/TIONMNUM*3RM

W3RTIFIW/TIONMFORMP/YM3NTM
F363R/LM
3MPLOY33M

BISON

Yr.(s)/Mo.(s)

BR336M

S3XM

PN*M
GR/63M

2M
TATTOOM

V/WWIN/TIONM
T/TTOOM

PRIV/T3M
4Owner’s
Expense8M
IMW3RTIFYMTH/TYM 4V8 IMhaveM vaccinatedM withM anM approvedM
vaccineZMoffically tattooedM andM eartaggedHMorMotherwiseM
officiallyHM individuallyMidentifiedM allM animalsM listedM hereonM asM
prescribedM byM theM *rucellosisMUMMandMRHM andM recordedM allM
informationM asM prescribedM byM StateM regulationsZ and
4C8M whenM paymentM isM claimedM atM theM program-sM expenseM inM accordanceM withM theM
agreementMnumber below,M noM paymentM hasM beenM orM willM beM receivedM fromM anyM otherM
sourceD

Signature

F33M*/SISM
4Federal8M

ST/T3M
WOUNTYM

6ateMofMVaccination

/greeDMWode

1

W3RTIFIW/TIONM OFMOWN3RM ORMWITN3SSM
IMW3RTIFYMTH/TMthe animals listed hereon were vaccinated and identified for the above named
owner.

2

Signature

6ate

3

W3RTIFIW/TIONMFORMR3E3ST/*LISHINGM V/WWIN/TIONMST/TUSM
4

2

5

I W3RTIFYMTH/TMIMhave personally examined the animal(s) noted hereon, and have read the official
tattoo(s), and have retagged them as shown.M

Indicate tattoo of animals previously vaccinated in appropriate column.M

Signature

6ate

6

NODM

7

8

21

9

22

10

23

11

24

12

25

13

26

14

27

15

28

16

29

17

30

18

31

19

32

20
VSMFORMM FECSM

33
JUNMCU14

/G3M
I63NTIFIW/TIONMNUM*3RM

YrD4s8/Mo.(s)

BR336M S3X

M

PN*M
GR/63M

2M
T/TTOOM

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.