VS 4-6 Telecopier Justification for Brucellosis Herd Depopulati

According to the Paperwork Reduction Act of 1995, an agency may not consider 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 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.

TELECOPIER JUSTIFICATION FOR
BRUCELLOSIS HERD
DEPOPULATIONS
4. NAME OF HERD OWNER

OMB APPROVED
0579-0047
EXP: XX/XXXX

1. SUBMITTED BY:

2. DATE
SUBMITTED

3. SUBMITTED TO:
5. STREET ADDRESS

6. COUNTY

Modified Certified

Free

7. STATE

TEST HISTORY (If more space is needed, attach additional sheets)
9. PLATE - TUBE
N
R
S

8. TEST
DATES

10. BBA
N
R

11. RIVANOL
N
TITER

13. DATE “R”
REMOVED
FROM FARM

12. OTHER RESULTS REMARKS

HERD HISTORY (Also submit a narrative report if necessary)
14. ISOLATIONS: (Results and dates)

15. MCI
Yes

Date (If yes)
No

17. ABORTIONS
Yes

Date (If yes)

16. BRT

Stockyards
Slaughter

Yes

Percent

No

%

Date (If yes)
Beef NA

No

18. STRAIN 19 CV HISTORY
Percent CV in adult herd
Percent CV in replacement heifers
%
%

19. CONTACT HERDS: (List contact herds with test results and dates)

20. ECONOMIC IMPACT ON HERD OWNER, IF NOT DEPOPULATED:

21. IMPACT ON MANHOURS IN STATE, IF NOT DEPOPULATED:

INVENTORY TO DEPOPULATE
Registered

22. NO. ADULTS
COWS
BULLS

23. NO. CALVES
FEMALE
MALE

24. STEERS
(Ineligible)

25. ESTIMATED
INDEMNITY
$

Grade
APPROVED BY
26. SIGNATURE OF STATE OFFICIAL

27. TITLE

28. DATE

29. SIGNATURE OF FEDERAL OFFICIAL

30. TITLE

31. DATE

32. SIGNATURE OF REGIONAL DIRECTOR

33. DATE

VS FORM 4-6
APR 2009

USDA – APHIS

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.