Form CS 336681-A CS 336681-A CDC Rabies Vaccination and Microchip Record

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

OMB Approval Number: 0920-1381
Form Expires: 01/31/2026
Form available at: www.cdc.gov/dogtravel

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

Address:

City:
Phone Number (including country and/or area code):

State:
American
Alaska
Alabama
District
Delaware
Connecticut
Colorado
California
Arkansas
Arizona
Nevada
Nebraska
Montana
Missouri
Mississippi
Minnesota
Michigan
Massachusetts
Maryland
Maine
Louisiana
Kentucky
Kansas
Iowa
Indiana
Illinois
Idaho
Hawaii
Guam
Georgia
Florida
New
North
Northern
Puerto
Pennsylvania
Oregon
Oklahoma
Ohio
Rhode
South
U.S.
Virginia
Vermont
Utah
Texas
Tennessee
West
Washington
Wyoming
Wisconsin
Virgin
Hampshire
Jersey
Mexico
York
Virginia
Carolina
Dakota
Carolina
Dakota
Rico
Island
ofMariana
Columbia
Samoa
IslandsIslands
Email address:

Zip Code:

SECTION B: ANIMAL IDENTIFICATION
ANIMAL NAME

ISO-COMPLIANT
MICROCHIP NUMBER

BREED

DATE OF
BIRTH OR AGE

SEX

(MM/DD/YYYY)

COLOR/MARKINGS

Female
Male
Intact
Neutered
Intact
Neutered

SECTION C: RABIES VACCINE INFORMATION

PRODUCT NAME

MANUFACTURER:

LOT NUMBER

PRODUCT
EXPIRATION DATE

DATE OF
VACCINATION

DATE NEXT
VACCINATION IS DUE

(MM/DD/YYYY)

(MM/DD/YYYY)

(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:

Date (MM/DD/YYYY):

Address of Veterinarian:
City:
Telephone (including country code):
Veterinary License Number:

±

Region/State:

Country:
Email address:

Antigua
Angola
Andorra
Algeria
Albania
Afghanistan
Azerbaijan
Austria
Australia
Armenia
Argentina
Bosnia
Bolivia
Bhutan
Benin
Belize
Belgium
Belarus
Barbados
Bangladesh
Bahrain
Burkina
Bulgaria
Brunei
Brazil
Botswana
Cape
Canada
Cameroon
Cambodia
Burundi
Central
Comoros
Colombia
China
Chile
Chad
Congo,
Costa
Cote
Czech
Cyprus
Cuba
Croatia
Dominican
Dominica
Djibouti
Denmark
East
El
Egypt
Ecuador
Equatorial
The
Gabon
France
Finland
Fiji
Ethiopia
Estonia
Eritrea
Kiribati
Kenya
Kazakhstan
Jordan
Japan
Jamaica
Italy
Israel
Ireland
Iraq
Iran
Indonesia
India
Iceland
Hungary
Honduras
Haiti
Guyana
Guinea-Bissau
Guinea
Guatemala
Grenada
Greece
Ghana
Germany
Georgia
Korea,
Marshall
Malta
Mali
Maldives
Malaysia
Malawi
Madagascar
Macedonia
Luxembourg
Lithuania
Liechtenstein
Libya
Liberia
Lesotho
Lebanon
Latvia
Laos
Kyrgyzstan
Kuwait
Kosovo
Micronesia,
Mexico
Mauritius
Mauritania
Myanmar
Mozambique
Morocco
Montenegro
Mongolia
Monaco
Moldova
New
Netherlands
Nepal
Nauru
Namibia
Papua
Panama
Palau
Pakistan
Oman
Norway
Nigeria
Niger
Nicaragua
Rwanda
Russia
Romania
Qatar
Portugal
Poland
Philippines
Peru
Paraguay
Saint
San
Samoa
Sao
Saudi
Sierra
Seychelles
Serbia
Senegal
Solomon
Slovenia
Slovakia
Singapore
Somalia
South
Sri
Spain
Trinidad
Tonga
Togo
Thailand
Tanzania
Tajikistan
Taiwan
Syria
Switzerland
Sweden
Swaziland
Suriname
Sudan
Ukraine
Uganda
Tuvalu
Turkmenistan
Turkey
Tunisia
United
Vatican
Vanuatu
Uzbekistan
Uruguay
Zimbabwe
Zambia
Yemen
Vietnam
Venezuela
Salvador
Lanka
Bahamas
Gambia
Marino
Tome
Zealand
Timor
d’Ivoire
Kitts
Lucia
Vincent
Verde
Arabia
Rica
Africa
Sudan
Leone
Republic
Arab
Kingdom
States
New
North
South
and
African
Republic
Democratic
City
Faso
and
and
Islands
Islands
(Burma)
Guinea
and
and
Republic
(Timor-Leste)
Herzegovina
Federated
Guinea
Emirates
(Holy
Barbuda
Tobago
and
ofNevis
Principe
Republic
America
ofthe
See)
the
Republic
Grenadines
Statesofofthe

Print form and affix veterinary seal if you do not have a veterinary license number.

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

1

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 0920-1381
CS 336681-A 12/21/2022