Form Veterinary Shortag Veterinary Shortag Veterinary Shortage Situation Nomination

NIFA Veterinary Medicine

Loan Repayment Program (VMLRP)

Shortage ID: VMLRP USE ONLY

National Institute of Food and Agriculture US Department of Agriculture

OMB No. 0524-0050

Form Approved For Use Through XX/XX/XXXX

VETERINARIAN SHORTAGE SITUATION NOMINATION FORM

Purpose: This form must be used for nomination of veterinarian shortage situations to the Veterinary Medicine Loan Repayment Program (VMLRP), authorized under the National Veterinary Medical Service Act (NVMSA). This form must be submitted under the authority of the Chief State or Insular Area Animal Health Official.

For Nominating Official: Submit one separate nomination form for each shortage situation. Visit the VMLRP Shortage Allocations section of the VMLRP web site (http://www.nifa.usda.gov/resource/vmlrp-shortage-allocations) for the number of nominations permitted for each state or insular area. Visit the Veterinary Shortage Situation Nomination Guide (https://www.nifa.usda.gov/grants/programs/veterinary-medicine-loan-repayment-program/vmlrp-veterinary-shortage-situation-nomination-guide) for a step-by-step guide to prepare and submit nominations.

1. Location of Veterinary Shortage Area for this Nomination

1. Must Service Location(s):

(County, State/Insular Area; must be contiguous and a logistically feasible veterinary practice service area)

2. May Service Location(s):

(County, State/Insular Area; must be contiguous with the Must Service Location(s) and a logistically feasible veterinary practice service area)

2. Type of Veterinary Practice Area/Discipline/Specialty (select one):

• Type I: Private practice (80% FTE commitment)

• Type II: Private practice (minimum 30% to maximum 80% FTE commitment)

• Type III: Public practice (minimum 49% to maximum 80% FTE commitment)

2. Optional: Specify the percent time in the box below based on a 40-hour work week.

%

2. For Private Practice, select species and/or production types to serve:

Must be willing and available to serve at least one and no more than two. All other agricultural species qualify to meet service commitment.

☐Beef Cattle

☐Dairy Cattle

☐Swine

☐Poultry

☐Small Ruminant

☐Other:

2. For Public Practice:

Employer: Position Title:

Please select one or more specialty/disciplinary areas:

☐Animal Health Regulatory

☐Diagnostician

☐Epidemiology

☐Food Safety

☐Public Health

☐Other:

3. Referring to the characteristics identified in response to question 2 above and the location to be served, describe in detail the need for a veterinarian in this shortage situation area. Include state, national, or local data to support the description of the need, such as numbers of animals, farms/ranches, markets, etc. (Limit your response to 2000 characters.)

4. Referring to the characteristics identified in response to question 3 above, describe the services that a veterinarian must be willing to provide to meet this shortage situation’s needs in the community, area, state/insular area, or position requested above. (Limit your response to 2000 characters.)

5. To help you promote your shortage nomination, what aspects of the community (outdoor activities, community strengths, etc.) would attract a veterinarian to the service area or state? What would be the major attractions for the veterinarian to join the community? (Limit your response to 2000 characters.)

6. Describe the consequences of this veterinary position not being secured or retained. Include the risk(s) to the production of a safe and wholesome food supply and to animal, human, and environmental health not only in the community but in the region, state/insular area, nation, and/or international community. Describe why this shortage is a critical, high, or moderate priority. (Limit your response to 2500 characters.)

7. SAHO nominator must check both boxes below in order for NIFA to consider this nomination for official designation.

1. By checking this box, I affirm that this form represents a nomination and is subject to NIFA review and approval.

2. By checking this box, I affirm that it is my professional opinion that this is a bona fide food supply or public health-related veterinary shortage situation. I affirm due diligence has been invested to identify this area as a shortage situation of at least moderate priority (severity).

3. Authorized State or Insular Area Animal Health Official or Designee:
   Name:

Title:

Organization:

Email:

Telephone Number:

(Area code required)

Public reporting for collection of information is estimated to average two hours, 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 current 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 NIFA, OGFM, 2312 East Bannister Road, Mail Stop 10,000, Kansas City, MO 64131, Attention Policy Section. Do not return the completed form to this address.

OMB No. 0524-0050

1

NIFA invests in and advances agricultural research, education, and extension and promotes transformative discoveries that solve societal challenges.

USDA is an equal opportunity lender, provider and employer.