0920-1383 Cdc Rabies Vaccination And Microchip Record

CDC logo here OMB Approval Number: 0920-1383

Form Expires: 01/31/2026

Form available at: www.cdc.gov/dogtravel

CDC RABIES VACCINATION AND MICROCHIP RECORD
This form is to be completed by the examining veterinarian

SECTION A: NAME AND ADDRESS OF OWNER IN THE UNITED STATES

Name:
Address:	City:		Region/State:	Country:
Phone Number (including country and/or area code):		Email Address:

SECTION B: ANIMAL IDENTIFICATION

ANIMAL NAME	ISO-COMPLIANT MICROCHIP NUMBER	BREED	SEX	DATE OF BIRTH (MM/DD/YYYY) OR AGE	COLOR/MARKINGS

SECTION C: RABIES VACCINE INFORMATION

PRODUCT NAME	MANUFACTURER	LOT NUMBER	PRODUCT EXPIRATION DATE (MM/DD/YYYY)	DATE OF VACCINATION (MM/DD/YYYY)	DATE NEXT VACCINATION IS DUE (MM/DD/YYYY)

SECTION D: VETERINARY CERTIFICATION STATEMENT

1. I certify that I examined the animal listed above and that the age, breed, sex, ISO-compliant microchip number, and description of the animal is true and correct.

2. I certify based on either having personally administered or supervised the administration of the vaccine or booster that: (1) the initial rabies vaccine was administered on or after 12 weeks (84 days) of age; or (2) the rabies booster vaccine was administered on or after 60 weeks (15 months) of age and the owner had proof that the animal received previous rabies vaccination that was administered on or after 12 weeks (84 days) of age.

3. To the best of my knowledge and belief, the animal described above did not come from an area under animal quarantine for rabies by a government authority and has not been exposed to rabies.

4. I certify that I am authorized by the competent authority¹ to practice veterinary medicine in the country listed below.

5. I hereby certify to the best of my knowledge and belief that that the information submitted herein is complete and accurate and that I understand that any false statement made in connection with this certification may subject me to criminal penalties under 18 U.S.C. 1001.

SIGNATURE OF EXAMINING^± VETERINARIAN:

I certify that all information provided on this form is true and accurate.
Veterinarian’s Signature:	Printed Name:
Address of Veterinarian:	City:	State or Region:	Country:
Telephone (including country code):	Email Address:
License Number or Official Seal:	Date (MM/DD/YYYY):

^± The examining veterinarian must be authorized by the competent authority to practice veterinary medicine in the exporting country or be an official government veterinarian.

1 Competent Authority means the minister, government department, or other authority having power to issue and enforce regulations, orders, or other instructions having the force of law in respect of the subject matter of the provision concerned.

Public reporting burden of this collection of information is estimated to average 15 minutes 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. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-1383