State, Local, Tribal Gov't

According to the Pa perwork Reduction Act of 1995, an agency may not conduct or s ponsor, 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-XXXX. T he time required to
complete this information colle ction is estimated to average 15-45 minutes 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.

OMB Approved
0579-XXXX
Exp. XX/XXXX

HPAI Response

Participating HPAI Dairy Premises Support Agreement
May 29, 2024

Note: This is an agreement for dairy premises to receive USDA financial support for up to 120 days.
Premises Information
Premises ID #
Special ID #
Premises owner
Name of premises
Address of premises
Contact person (for premises)
Contact phone number
Contact e-mail address
Business Owner (if different from premises owner)
Name of authorized representative, if applicable
Address of business owner
Bovines present on premises (include number, sex, age, stage of lactation, if applicable)

PRODUCER (OWNER/OPERATOR):
Signature:

(ink signature required)

Date:

☐VS INCIDENT COMMANDER, DEPUTY IC OR ☐VS DISTRICT DIRECTOR/AREA VETERINARIAN IN CHARGE
Signature:

Date:

☐STATE INCIDENT COMMANDER OR ☐STATE VETERINARIAN:
Signature:

Date:

This is a written agreement developed between USDA APHIS Veterinary Services (VS) and
(Insert Producer (owner/operator); hereafter, “the Producer”). This herd will be
handled in accordance with any additional
(Insert name of State)
regulations/requirements.

This agreement allows the premises to receive financial support from USDA APHIS in response to the HPAI H5N1
outbreak in dairy cattle.
By signing this document, the Producer is indicating a willingness to participate in available support options as
outlined below. This document does not authorize payments to the Producer. Additional instructions regarding how
to receive payments can be found under the Agreement and Reimbursement Process on page 3.
The Producer may request modifications to these procedures at any time by contacting the AVIC or SAHO (or
designee). The procedures in this document will remain in effect until USDA APHIS VS approves modifications to this
agreement.
☐ The Producer has been presented with the option and declines to participate in the financial support options for

HPAI affected premises at this time.

AVAILABLE SUPPORT OPTIONS FOR UNAFFECTED PREMISES (PRODUCER TO SELECT DESIRED
OPTIONS)

☐ SUPPORT FOR BIOSECURITY PLANNING AND IMPLEMENTATION. Provide support (up to $1,500 per

premises) to develop and implement biosecurity plans based on existing secure milk supply plans. This includes
recommended enhanced biosecurity for individuals that frequently move between dairy farms – milk haulers,
veterinarians, feed trucks, AI technicians, etc. In addition, USDA will provide financial support to the Producer to
purchase and use an in-line sampler for their milk system, up to $100 per premises.
If the Producer elects to hire private entities to develop site specific plans, conduct biosecurity trainings,
and perform audits: the Producer will be compensated up to $1,500 per premises for these services after
verification and inclusion on the Dairy HPAI Expense Tracker. The Producer will need to provide proof of
contract/purchase of biosecurity planning. APHIS may conduct onsite visits to verify implementation of
the biosecurity plan.
If the Producer elects to work with State Animal Health personnel to develop site specific plans, conduct
biosecurity trainings, and perform audits. This service by the State will be free to the Producer: USDA will
compensate States directly for this service.
The Producer will need to provide receipt for proof of purchase and installation of the in-line sampler.

☐ REIMBURSE THE PRODUCER FOR VETERINARY COSTS ASSOCIATED SAMPLE COLLECTION FOR
H5N1 TESTING. This provides support to the Producer to cover fees for veterinarians to collect samples for

H5N1 testing. Veterinary sample collection costs are eligible to be covered from the April 29, 2024 (the date the
Federal Order went into effect) for that premises, up to $2,000 per premises.
The Producer will need to provide paid veterinary bills associated with sample collection.

☐ OFFSET SHIPPING COSTS FOR INFLUENZA A TESTING AT LABORATORIES IN THE NATIONAL
ANIMAL HEALTH LABORATORY NETWORK (NAHLN). USDA will pay for the cost of shipping samples to

NAHLN labs for testing. USDA will pay actual shipping costs, not to exceed $50 per shipment for up to 2 shipments

Owner Initials:

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Version: May 29, 2024

pg. 2

per month for each premises. Testing at NAHLN laboratories for samples associated with this event (e.g., premovement, testing of sick/suspect animals, samples from concerned producers) is already being conducted at nocost to the Producer.
The Producer will need to provide receipts for sample shipping costs.

AGREEMENT AND REIMBURSEMENT PROCESSES

Upon signature of this agreement, the Producer will be provided with information to sign up for a System for
Award Management (SAM) registration, which will provide for the mechanism of payment, or offered an
alternative method of payment (e.g., providing an EFT form for direct deposit payments, requesting a paper check
be drafted), although these other options will result in less timely payments compared to SAM.
Additionally, an APHIS representative will work with the Producer to develop a detailed financial plan to include all
the planned activities, purchases and services that will be eligible for reimbursement.
Every 30 days, the Producer will be provided a form (VS 8-18) to review and sign verifying the request for
reimbursement. The Producer may also elect to be reimbursed one time at the end of the 120 days. The Producer
will keep all receipts and will be required to present receipts with the 8-18.

OPTIONS FOR REIMBURSEMENT
☐ MONTHLY REIMBURSEMENT

☐ ONE TIME PAYMENT AT THE END OF 120 DAYS

Owner Initials:

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Version: May 29, 2024

pg. 3