VS Form 1-36A National Veterinary Accreditation Program Application Fo

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 0579-0297. The time required to complete this collection of
information is estimated to average .4 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.
1. Initial Accreditation

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

State

OMB Approved
0579-0297
Exp. Date: xx/xxxx

2. Authorization in an Additional State
License Number

State

License Number

3. Change Accreditation Category (block 18 or 19)

4. Contact Information Change

5. Accreditation Renewal or Reinstatement

6. Post-Revocation Re-Accreditation

NATIONAL VETERINARY ACCREDITATION PROGRAM

APPLICATION FORM
7. Name of Veterinarian (Last, First, M, Suffix)

Check if your name has changed 8. Six-Digit National Accreditation Number

9. Other Names Used (e.g. Maiden Name)

10. Date of Birth

13. State where Orientation Completed

11. School of Veterinary Medicine

14. Date Orientation Completed

15. Date Initial Accreditation Training Completed

16. Are you interested in participating in State or Federal agricultural emergency response efforts?
Yes

12. Year Graduated

17. Check box if you are a full time U.S. Military Veterinarian

(Reservists and National Guard personnel, do not check this box)

No

ACCREDITATION CATEGORY SELECTION complete only one block, 18 or 19
18.
Category I Animals (includes canines, felines, amphibians/reptiles not raised for
human consumption, furbearing animals, laboratory animals (rodents), and non-human primates)

19.

Refer to Explanation of Codes Page

Refer to Explanation of Codes Page

Practice Code:
(select one)

3

4

8

9

Category II Animals (includes all animals)

Practice Code:
(list one)

Species Code(s):
1
2
12
16
17 (rodents)
18
(select up to four; this does not limit the number of Category I species upon which you may
perform accredited duties)

Species Code(s):

Primary Medical Discipline

Primary Medical Discipline

Employment Type

Employment Type

(list up to four; this does not limit the number
of species upon which you may perform
accredited duties)

CONTACT INFORMATION
20. Home Mailing Address

24. Business Name and Mailing Address

21. County of Home Mailing Address

25. County of Business Mailing Address

22. Home Phone

26. Business Phone

23. Email Address-Mandatory to Maintain your Accreditation

28. Business Cell Phone

29. May your business contact information be released to the public by the USDA?

Yes

27. Business FAX

No

ACCREDITATION RENEWAL, REINSTATEMENT, OR CHANGE OF ACCREDITATION CATEGORY – complete only if block 3 or block 5 are selected
Enter the module numbers, not names, of the APHIS approved supplemental training modules you have completed.
Category I veterinarians: three modules; Category II veterinarians: six modules.
30. Module Number
31. Course Type
32. Date Module
Completed
I certify that I am able to perform the tasks listed in 9 CFR Part 161.1(g) for the appropriate Accreditation category in Blocks 15 or 16. I agree to conduct all activities as an accredited veterinarian in
accordance with the Standards of Accredited Veterinarian Duties contained in Title 9, Code of Federal Regulations. Subchapter 3, Part 161.4 and any amendments thereto which may subsequently be issued
and in accordance with instructions received from the Veterinary Official. I certify that I have completed all modules listed in Blocks 30-32. I certify that I understand it is my responsibility to notify APHIS when
one of my veterinary licenses lapses or become inactive, and when my contact information changes.
33. Signature of Veterinarian

34. Date

Signature of the Veterinarian-in-Charge and the State Animal Health Official appearing below denotes endorsement of the applicant for Initial Accreditation and/or Post-Revocation
Re-Accreditation.
35. Signature of State Animal Health Official

36. Date

37. Signature of Veterinarian-in-Charge

38. Date

VS FORM 1-36A
SEP 2023

PRIVACY ACT NOTICE
General:
This information is provided pursuant to Public Law 95-3579 (Privacy Act of 1974) December 31, 1974, for individuals completing the VS 1-36A.
Authority:
5 U.S.C. 3301, 7 U.S.C. 8309, and 21 U.S.C. 113a
Routine Uses:
The information will be used for (1) Referral to State Animal Health officials to certify accreditation status or to exchange information regarding disciplinary action(s). (2)
Referral to state veterinary examining boards to certify accreditation status or to exchange information regarding disciplinary action(s). (3) Disclosure to the public for the
purpose of locating and contacting accredited veterinarians for a specific geographical location. (4) Referral to the appropriate agency, whether Federal, State, local or
foreign, charged with the responsibility of investigating or prosecuting a violation of law, or of enforcing or implementing a statute, rule, regulation or order issued pursuant
there to, of any record within this system when information available indicates a violation or potential violation of law, whether civil, criminal or regulatory in nature, and
whatever arising by general statue or particular program statue, or by rule, regulation or order issued pursuant thereto. (5) Disclosure to the Department of Justice has
agreed to represent the employee or the United States, where the agency determined 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 be 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. (6) Disclosure in a proceeding before a court of 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 (7) Disclosure to appropriate agencies, entities, and persons when the agency suspects or has confirmed
that the security or confidentiality of information in the system of records has been compromised; the agency has determined that as a result of the suspected or confirmed
compromise there is a risk of harm to economic or property interests, a risk of identity theft or fraud, or a risk of harm to the security or integrity of this system or other
systems or programs (whether maintained by the agency or another agency or entity) that rely upon the compromised information; and the disclosure made to such
agencies, entities, and persons is reasonably necessary to assist in connection with the agency’s efforts to respond to the suspected or confirmed compromise and
prevent, minimize, or remedy such harm; (8) Disclosure to cooperative Federal, State, and local government officials, employees, or contractors, and other parties engaged
to assist in administering the program. Such contractors and other parties will be bound by the nondisclosure provisions of the Privacy Act. This routine use assists the
agency in carrying out the program, and thus is compatible with the purpose for which the records are created and maintained. (9) Disclosure to USDA contractors, partner
agency employees or contractors, or private industry employed to identify patterns, trends or anomalies indicative of fraud, waste, or abuse. (10) Disclosure to the National
Archives and Records Administration or to the General Services Administration for records management inspections conducted under 44 U.S.C. 2904 and 2906.
Effects of Nondisclosure:
Although this information is voluntary, failure to complete all the information may delay the process of the application or it may result in the application not being processed.

Instructions for Completing VS Form 1-36A, National Veterinary Accreditation Program (NVAP) Application
Block 1. Initial Accreditation: Check this block if you are applying for
initial accreditation. Enter the two-letter State abbreviation and your
complete veterinary license number for this State. Complete blocks 1, 7,
9 (if applicable), 10, 11, 12, 13, 14, 15/16, 17-33, 37, and 38.

Species Code(s): Enter up to four code(s) associated with the species
with which you most often expect to perform accredited duties. These
entries do not limit the species on which you may perform accredited
duties within your Accreditation Category.

Block 2. Authorization in an additional State: Check this block if you
are seeking authorization to perform accredited duties in an additional
State. Enter the two-letter State abbreviation and your complete
veterinary license number for this State. Complete blocks 2, 7, 8, 9 (if
applicable) 10, 17-33, 37, and 38.

Primary Medical Discipline: Enter the number associated with the
discipline that best describes your primary medical discipline.

Block 3. Change Accreditation Category: Check this block if you are
changing your Accreditation Category. Complete blocks, 3, 7, 8, 10,
15/16,
and 34-38.
Block 4. Contact Information Change: Check this block if you are
changing your contact information (e.g., name, address). Complete
blocks 4, 7, 8, 10, 37, 38, and the appropriate CONTACT
INFORMATION fields.
Block 5. Accreditation Renewal or Reinstatement: Check this block if
you are renewing your accreditation or reinstating your accreditation after it
has expired. Complete blocks 5, 7, 8, 10, and 34-38. You may not apply for
renewal prior to 6 months of your renewal date.
Block 6. Post -Revocation Re-Accreditation: Check this block if your
accreditation was revoked and you are applying for reaccreditation.
Complete blocks 6, 7, 8, 10, 15/16, 17-33, 37, and 38.
Block 7. Name of Veterinarian: Enter your legal last name, first name
and middle initial. (If this is a name change request, enter your new legal
name in this block.) Check the block, if your name has changed and
complete Block 9.
Block 8. Six-Digit National Accreditation No.: Enter the National
Accreditation Number that you have been assigned.
Block 9. Other Names Used (e.g., Maiden Name): Enter other names
used – for example, maiden name, nickname (this name should not be
the same name as in block 7).
Block 10. Date of Birth: Enter the two-digit month, two-digit day, and
four- digit year of your birth.
Block 11. School of Veterinary Medicine: Enter the name of the
school of veterinary medicine from which you graduated.
Block 12. Year Graduated: Enter your four-digit year of graduation from
a school of veterinary medicine.
Block 13. State where Orientation Completed: Enter the two letter
abbreviation of the State where core orientation was completed.
Block 14. Date Orientation Completed
Block 15. Date Initial Accreditation Training Completed
Block 16. Are you interested in participating in State or Federal
agricultural emergency response efforts? Check “yes” or “no”, if you
would like to be contacted to assist with agricultural emergency response
efforts.
Block 17. Check box if you are a full time U.S. Military Veterinarian.
Reservists and National Guard personnel, do not check box.
Category Selection (Refer to Explanation of Codes)
Block 18. Category I: Check this block for authorization to only perform
accredited duties on canines, felines, amphibians/reptiles, furbearing
animals, laboratory animals (rodents), and/or non-human primates.
Block 19. Category II: Check this block for authorization to perform
accredited duties on all animals.
Practice Code: Enter the code which most clearly describes the species
upon which you will perform accredited duties.

Employment Type: Enter the number associated with your employment
type.
Home Contact Information
Block 20. Home Mailing Address: Enter your complete home
mailing address. This is the address that will be used by NVAP to
communicate with you.
Block 21. County of Home Mailing Address: Enter the county in
which your home address is located.
Block 22. Home Phone: Enter your 10-digit home phone number.
Block 23. Email Address: Enter your email address. (NOTE: If you
enter a shared email address, that information may be viewed by
others.)
Business Contact Information
Block 24. Business Name and Mailing Address: Enter the name of
the business where you work/practice. If you are self-employed
without a specific business name, enter your name from Block 7.
Enter complete business mailing address. If your home mailing address is
your business mailing address, write “Same as home address.”
Block 25. County of Business Mailing Address: Enter the county in
which your business address is located.
Block 26. Business Phone: Enter your 10-digit business phone
number.
Block 27. Business FAX: Enter your 10-digit fax number.
Block 28. Business Cell Phone: Enter your 10-digit cell phone number.
Block 29. May your business contact information be released to
the public by the USDA? Check "yes" or "no" to having your
business contact information released, which determines if clients can
find you using the “Find an Accredited Veterinarian” Public Search
tool on our website.
Block 30. Module Number: Enter the module numbers, not the
names, of the APHIS approved supplemental training modules you
have completed. Category I veterinarians: three modules; Category II
veterinarians: six modules
Block 31. Course Type: Enter Online or Lecture to describe how
you completed each module.

Block 32. Date Module Completed: Enter the two-digit month, twodigit day, and four-digit year that you completed the module.
Certification/Approval
Block 33. Signature of Veterinarian: Read the certification
statement above block 33 and sign in blue or black ink, digitally sign,
or digitally draw your signature. (NOTE: You MUST be licensed or
legally able to practice as a veterinarian.)
Block 34. Date: Enter the two-digit month, two-digit day, and fourdigit year that you signed this application.
Blocks 35-38: Do not enter any information in these blocks.

Explanation of Codes
Practice Codes (Blocks 15 & 16)
(May indicate up to 2 codes)
(“Predominant” = Greater than 50%
Species Contact,
“Exclusive” = Only Species Contact)
1 - Food Animal Predominant
2 - Food Animal Exclusive
3 - Companion Animal Predominant
4 - Companion Animal Exclusive
5 - Mixed Animal
6 - Equine Predominant
7 - Equine Exclusive
8 - Other
9 - No Species Contact
Species Codes (Blocks 15 & 16)
(May choose up to 4 codes)
1 - Canine
2 - Feline
3 - Equine
4 - Bovine
5 - Porcine
6 - Ovine/Caprine
7 - Camelid
8 - Cervid
9 - Poultry
10 - Avian (non-poultry)
11 - Exotics
12 - Amphibian/Reptile
13 - Aquatic Animal
14 - Zoo Animal
15 - Wildlife
16 - Furbearing Animals
17 - Laboratory Animal
18 - Non-Human Primate
19 - Other Species
20 - No Species Contact
Primary Medical Disciplines
(Blocks 15 & 16)
(Choose only 1 discipline)
1 - Anatomy
2 - Anesthesiology
3 - Animal Behavior
4 - Animal Welfare
5 - Alternative/Contemporary
6 - Association Management
7 - Biochemistry
8 - Biomedical Engineering

910 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 -

Business/Economics
Cardiology
Dentistry
Dermatology
Disaster Medicine
Ecology
Emergency and Critical Care
Endocrinology
Environmental Health
Epidemiology
Ethics
General Medicine
Genetics
Human Animals Bond
Homeland Security
Immunology
Internal Medicine
Insurance
Laboratory Animal Medicine
Law
Media
Microbiology
Mycology/Bacteriology
Molecular Biology
Neurology
Non-Medical
Nutrition
Oncology
Ophthalmology
Parasitology
Pathology - Anatomic
Pathology – Clinical
Pharmacology
Pharmacology – Clinical
Physiology
Population Medicine
Poultry Medicine
Preventative Medicine
Production Medicine
Public Health
Radiology
Shelter Medicine
Sports Medicine
Surgery
Theriogenology
Toxicology
Virology
Wildlife Medicine
Zoological Medicine

58 - Other Professional Discipline
Employment Type (Blocks 15 & 16)
(May choose only 1 type)
Private Clinical Practice
1 - General Medicine/Surgery
2 - Production Medicine
3 - Referral/Specialty Medicine
4 - Emergency/Critical Care Medicine
5 - Other Private Clinical Practice
Academia
6 - Veterinary Medical College/School
7 - Veterinary Science Department
8 - Veterinary Technician Program
9 - Animal Science Department
10 - Other Academia
Government
11 - U.S. Federal
12 - State
13 - Local
14 - Foreign
15 - Army
16 - Air Force
17 - Public Health Commission Corps
18 - Other Government
Industry/Commercial
19 - Pharmaceutical/Biological
20 - Feeds/Nutrition
21 - Laboratory
22 - Agriculture/Livestock Production
23 - Business/Consulting Services
24 - Other Industry/Commercial
Other
25 - Humane Organization
26 - Membership Assn/Professional
Society
27 - Foundation/Charitable Organization
28 - Missionary/Service
29 - Zoo/Aquarium
30 - Wildlife
32 - Temp Not Employment in Veterinary
Field
33 - Non-Veterinary Employment
34 - Not Employed
35 - Not Listed Above

This Professional Classification System is used courtesy of the American Veterinary Medical Association.