16–2

VS Form 1–27: Permit for Movement of Animals

1. Complete name and mailing address. If animals 

are being reconsigned from a market has purchased 

the animals and is, in fact, the owner/shipper.

2. Complete name and address of the owner at 

the time the physical condition was diagnosed. 

May be the same as item 1.

3. Self-explanatory.

4. This should be the complete name and address 

of a slaughter establishment or a quarantined feedlot. If the permit is for eggs, this will be the address 

of the break ing establishment.

5. Self-explanatory.

6. Self-explanatory.

7. Write in “other” if for eggs.

8. State disease suspected or diagnosed.

9. Exposed, suspect, infected.

10. Infected, exposed, suspect, etc. Use “N/A” if animals 

are a combined lot being reconsigned from 

a market.

 11. Status of the geographic area as it applies to the 

disease involved (e.g., quaran tine, free, etc.).

 12. If poultry products, write in the number of cases, 

boxes, crates, etc.

 13. Self-explanatory.

14. Self-explanatory.

15. Record the seal number used. Seals are not used on 

poultry trucks but are used on eggs whose movement is restricted because of Salmonella enteritidis.

16. Mark appropriate box. Check with your State Veterinarian or Area Veterinarian-in -Charge if in doubt.

17. a. Record all permanent identifi cation present.

b. Use breed codes.

c. M = male, F = female, N = neutered.

If the animal has a current permit number, list the 

identification number from the original permit 

that authorized movement to the current location. 

List any nonpermanent identifi cation (e.g., sale 

tags, backtags, bangle tags, etc.). Identify poultry by 

strain. Identify poultry products by type, (e.g., eggs, 

manure, etc.).

18. This is a legal document; do not forget to sign it.

19. Self-explanatory.

20. Self-explanatory.

21. Allow a reasonable amount of time for the 

movement to take place.

22. Allow a reasonable amount of time for the 

movement to take place.

23. If the owner or shipper is not available, the trucker 

may sign. Never allow a mem ber of the market 

organization to sign unless the market is the buyer 

or shipper.

24. Mark appropriate box. If the trucker signed, write 

in “trucker.”

25. Self-explanatory.

26–29. Self-explanatory. For slaughter animals and 

poultry, if the inspector cannot certify as to receipt 

and slaughter from his or her personal knowledge, 

and if plant management satisfies the inspector that 

the animals or poultry have, in fact, been handled 

properly, the inspector can insert above item 28 the 

phrase “Plant Records” or “Plant Management” and 

then sign item 33 and date item 34.

For animals shipped to a quarantined feedlot, 

whenever the inspector cannot verify arrival 

through direct inspection and count, he or she can 

insert above item 28 the phrase “animals on hand,” 

or “quarantined feedlot records,” etc., and then sign 

item 33 and date item 34.

For swine shipped from slaughter market to slaughter market, the inspector must verify arrival of all 

permitted swine by direct inspection and count.

30. Must be completed if the “yes” box in item 16 

is marked.

 31. Must be completed if the “yes” box in item 16 

is marked.

After completion of the form, items 1–25, the white 

copy accompanies the shipment. If the shipment 

is for slaughter, the green copy is addressed to the 

USDA–Food Safety and Inspection Service (FSIS) 

or State inspector at the designated slaughtering 

establishment. The FSIS or the State inspector will 

then complete the form and return it to the State 

of origin. If the shipment is poultry products, the 

green copy goes to the USDA–Agricultural Marketing Service inspector located at the destination. The 

pink copy goes to the APHIS Veterinary Services 

area office in the State of destination. The yellow 

copy goes to the APHIS Veterinary Ser vices area 

office in the State of origin. The issuing offi cial 

keeps the goldenrod copy.
16–3

SAMPLE
16–4

SAMPLE
16-5 

General Information on Appendix D

All pre-numbered APHIS and VS forms are accountable documents and failure to provide security 

for the forms is a violation of your accredited status. These forms may be ordered from your APHISVS Area Office. 

If you have any questions about completing these forms, you can contact your APHIS-VS Area Office 

at: https://www.aphis.usda.gov/aphis/ourfocus/animalhealth/contact-us/sa_area_offices/

ct_area_offices_avic

The new VS Form 10-4 Specimen Submission form for NVSL is not pre-numbered and my be 

completed on line, printed out, and included with your specimens sent to NVSL The electronic form

is available at: 

http://www.aphis.usda.gov/aphis/ourfocus/animalhealth/lab-info-services/

sa_forms_publications/ct_forms_publications

Veterinary Services is developing an electronic system where many of these forms as well as some 

of the international Official Health Certificates (OHC) of foreign destination countries will be 

available on line. The VS form 10-11, Equine Infectious Anemia Laboratory Test, is already available 

in the VSPS. The form can be completed on line in VSPS and transmitted electronically to the 

laboratories that have linked up with VSPS. The electronic EIA test record has the capability to 

upload digital photos of the horse.
16-6 

VS Form 4 – 24: Brucellosis Vaccination Record____________________________

STATE, COUNTY, AND CODE

Enter the complete State and county name. If appropriate, use the county code assigned by your SAHO or 

AVIC.

HERD NUMBER, OWNER NUMBER

Herd and owner numbers are assigned by the State. You may or may not have them when you complete 

the form.

KIND OF HERD

Mark the appropriate box. 

REMARKS, WBBS

[Leave blank.]

HERD OWNER

Enter the complete name and mailing address of the owner. 

CV, AV

Mark whether this is a calfhood vaccination or adult vaccination. 

LOCATION

Use the appropriate codes for these items. Check with your SAHO or AVIC. 

VACCINE USED

Enter the name of the biological supply company producing the vaccine used.

EXPIRATION DATE

Enter the expiration date of the vaccine.

SERIAL NUMBER

Enter the serial number of the vaccine.

DOSAGE

Mark the appropriate box. 

VACC. TATTOO

Enter the vaccination tattoo used. See “Brucellosis Eradication: Uniform Methods and Rules” to 

determine the proper tattoo. 

CERTIFICATION FOR PAYMENT

Mark the appropriate box. 

SIGNATURE

This is a legal document; be sure to sign it.

DATE OF VACCINATION

Enter the date that the vaccination was performed. 

AGREE. CODE

Enter your agreement code provided by the State. 

CERTIFICATION OF OWNER OR WITNESS

Have the owner or a witness sign and date the form. 

CERTIFICATION FOR RE-ESTABLISHING

VACCINATION STATUS

Mark this block if calfhood vaccinates are being retagged. Sign and date. Retagging is always done at the 

owner’s expense. 

IDENTIFICATION NUMBER 

Enter the calfhood vaccination tag number from the eartag that you are applying. Note any other 

permanent identification numbers, if present. 

AGE (MO.) List the age in months.

BREED Use the breed codes listed in table 3. 

SEX Enter F.

P/B-GRADE Mark this block if the animals are purebred (registered) or grade calves.

TATTOO List the present tattoo if retagging.
16–7

SAMPLE
16-8 

VS Form 4 – 26: Brucellosis Vaccination Record____________________________

STATE, COUNTY, AND CODE

Enter the complete State and county name. If appropriate, use the county code assigned by your SAHO or 

AVIC.

HERD NUMBER, OWNER NUMBER

Herd and owner numbers are assigned by the State. You may or may not have them when you complete 

the form.

KIND OF HERD

Mark the appropriate box. 

REMARKS, WBBS

[Leave blank.]

HERD OWNER

Enter the complete name and mailing address of the owner. 

CV, AV

Mark whether this is a calfhood vaccination or adult vaccination. 

LOCATION

Use the appropriate codes for these items. Check with your SAHO or AVIC. 

VACCINE USED

Enter the name of the biological supply company producing the vaccine used.

EXPIRATION DATE

Enter the expiration date of the vaccine.

SERIAL NUMBER

Enter the serial number of the vaccine.

DOSAGE

Mark the appropriate box. 

VACC. TATTOO

Enter the vaccination tattoo used. See “Brucellosis Eradication: Uniform Methods and Rules” to 

determine the proper tattoo. 

CERTIFICATION FOR PAYMENT

Mark the appropriate box. 

SIGNATURE

This is a legal document; be sure to sign it.

DATE OF VACCINATION

Enter the date that the vaccination was performed. 

AGREE. CODE

Enter your agreement code provided by the State. 

CERTIFICATION OF OWNER OR WITNESS

Have the owner or a witness sign and date the form. 

CERTIFICATION FOR RE-ESTABLISHING

VACCINATION STATUS

Mark this block if calfhood vaccinates are being retagged. Sign and date. Retagging is always done at the 

owner’s expense. 

IDENTIFICATION NUMBER 

Enter the calfhood vaccination tag number from the eartag that you are applying. Note any other 

permanent identification numbers, if present. 

AGE (MO.) List the age in months.

BREED Use the breed codes listed in table 3. 

SEX Enter F.

P/B-GRADE Mark this block if the animals are purebred (registered) or grade calves.

TATTOO List the present tattoo if retagging.
16–9

SAMPLE
16-10

VS Form 4 – 33: Brucellosis Test Record___________________________________ 

STATE, COUNTY

Enter the location of the herd; it may not be the same as the owner’s residence.

CODE

Enter the correct county code if instructed by your SAHO or AVIC. If you do not know the correct code, 

leave the block blank.

HERD OWNER

Enter last name, first name, middle initial, and complete mailing address. Be consistent among tests for 

the same owner — for example, James Jones v. J. Jones v. Jones Bros. 

LOCATION CODES

Enter the location codes if appropriate and/or known. Check with the SAHO or AVIC for specific 

information.

REASON FOR TEST

Indicate whether this is the initial test or a retest. If you check the retest block, enter that test date in the

PREVIOUS TEST DATE block. The vet code is assigned by your State. This information may be preprinted 

on the form. Indicate the reason for the test (e.g., export). If none of the first 9 reasons apply, check item 

10, Other, and briefly explain in the REMARKS block. 

COMPLETE HERD TEST OF ALL ELIGIBLE ANIMALS

Check either Yes or No to indicate whether this test is a complete herd test (all eligible animals are being 

tested). Enter the number of eligible animals in the herd. 

KIND OF HERD

Enter the type of herd-dairy, beef, or mixed, or swine, or other (e.g., caprine). 

AGREE. CODE

Certification for payment may be fee-basis or private, depending on the State. Your agreement code is 

assigned by your SAHO or AVIC. 

SIGNATURE

Sign the form and provide your address. Remember, this is a legal document; be sure to sign it. Provide 

the complete address, including ZIP Code. (The date should be the date the animal was bled.) 

TUBE NO.

Follow instructions from the laboratory you use on how to number the tubes. 

SIGNATURE

This is a legal document; be sure to sign it.

DATE OF VACCINATION

Enter the date that the vaccination was performed. 

AGREE. CODE

Enter your agreement code provided by the State. 

CERTIFICATION OF OWNER OR WITNESS

Have the owner or a witness sign and date the form. 

CERTIFICATION FOR RE-ESTABLISHING VACCINATION STATUS

Mark this block if calfhood vaccinates are being retagged. Sign and date. Retagging is always done at the 

owner’s expense. 

IDENTIFICATION NUMBER

Enter the vaccination tag number from the eartag that you are applying. Note any other permanent 

identification numbers, if present. 

AGE (MO.) List the age in months. 

BREED Use the breed codes listed in table 3. 

SEX Enter F.

P/B-GRADE Mark this block if the animals are purebred (registered) or grade calves.

TATTOO List the present tattoo if retagging.
16–11

Using VS Form 4 – 33 for Swine with Pseudorabies

Check first with the State office in the State where the 

swine are located to be sure that the State does not have 

its own offi cial pseudorabies test form. If there is an 

offi cial State form, use it. Otherwise, alter VS Form 4–33 

as follows: 

1. At the top of the form, delete BRUCELLOSIS 

and print PSEUDORABIES. Also print 

PSEUDORABIES in the REMARKS block. 

2. When testing for the Cooperative State–

Federal– Industry Pseudorabies Eradication Program, 

if you check block 6, 8, or 9, you must 

also do the following: 

• If block 6 is checked, enter one of the following 

in the REMARKS block:

Feeder-pig monitoring

Qualifi ed-negative (QN) herd test

QN-vaccinated herd test

Retest of infected herds

Retest of imported swine

Gene-altered vaccinated herd test

Other 

• If block 8 is checked, enter one of the following 

in the REMARKS block:

Breeding herd

Grower/finisher herd

Farrow to fi nish 

• If block 9 is checked, enter one of the following 

in the REMARKS block: 

Tracing movements of infected herds

Tracing source of additions to infected herds

Circle-testing around infected herds

[Explanation for any other 

epidemiologic reason] 

3. Permanent identification includes offi cial 

eartag, tattoo, and ear notching. 

4. If the herd that you are testing is vaccinated, 

use the REMARKS block to list the type and brand 

name of vaccine used.
16–12

SAMPLE
16–13

SAMPLE
16–14

VS Form 4 – 54: Brucellosis Test Record: Market Cattle Testing Program

STATE

Enter the name of the State. 

SAMPLES DRAWN AT

Mark the appropriate box. 

ESTAB. NUMBER

Enter the unique number assigned to each establishment (slaughterhouse or livestock market). You may 

obtain these numbers from the Veterinary Services area 

office in your State. 

NAME AND ADDRESS OF PLACE WHERE SAMPLES 

WERE DRAWN

Enter the complete name and mailing address. 

CERTIFICATION

Sign the form and enter the date that the samples 

were drawn. 

TESTING LABORATORY

If the blood samples are being sent to a laboratory, leave 

this block blank; the laboratory will fill it in. If you are 

collecting the samples at a market and conducting the 

tests yourself, fi ll in the information. Enter the name of 

the laboratory and the address where you are actually 

conducting the tests. 

TEST RESULTS

If the samples are sent to a laboratory, leave this area 

blank. If you are conducting the tests, enter the results. 

TUBE NO.

Self-explanatory. 

SALES TAG OR BRAND

Self-explanatory. 

BACK TAG NUMBER

Self-explanatory. 

EARTAG NUMBER

Self-explanatory. 

VACC. TATTOO

List the vaccination tattoo, if present. 

AGE

Enter the age in years or months. Indicate which you 

are using by placing an M or Y after the number. 

BREED

Enter the proper breed code. 

SEX

Enter M or F. 

COUNTY

List the county of origin of the cattle. If unknown, 

leave blank. 

HERD OWNER’S NAME

Self-explanatory. 

ADDRESS

Enter the address of the herd owner.
16–15

SAMPLE
16–16

VS Form 6 – 22: Tuberculosis Test Record

STATE Enter the State name.

COUNTY

Use Federal Information Processing Standards county 

code. A list for your State can be obtained from the 

Veterinary Services area office. If you cannot obtain the 

county code, leave the box blank. Enter the township or 

section code if applicable.

HERD OWNER

Enter the complete name and mailing address of the 

herd owner.

HERD NUMBER

The herd number is assigned by your State. If this is a 

retest, you should know the number. If this is an initial 

test, you may not know the number.

LESION, TEST, D-B, and U blocks [Leave blank.]

TOWNSHIP OR DISTRICT

Fill in names of county, township, or district, section, 

and farm number, as applicable. (Some States have offi cial farm numbers. If this is true in your State, the 

numbers can be obtained from the Veterinary Services 

area office in your State.)

REASON FOR TEST

Mark the appropriate box. If you mark OTHER, state 

the reason.

PREVIOUS TEST DATE

Complete this block only if this is a retest. The Vet Code 

is assigned by your State.

COMPLETE HERD TEST OF ALL ELIGIBLE ANIMALS

Mark yes or no. Provide the total number of animals in 

the herd.

KIND OF HERD Mark the appropriate box.

METHOD OF TEST Mark the appropriate box.

SUMMARY

Complete this block after testing. Fill in the number of 

animals in each category.

CERTIFICATION FOR PAYMENT

Mark the appropriate box.

SIGNATURE, AGREE. CODE

This is a legal document; be sure to sign it. Your agreement code is assigned by your State.

INJECTION, OBSERVATION

List the date and time that the injection was made and 

the date and time that the test was read (OBSERVATION).

REACTORS TAGGED AND BRANDED, AGREE. CODE

Enter the signature and agreement code of the veterinarian tagging and branding any reactors. This person 

may be different from the one filling out the rest of the 

form. Include the date of tagging and branding.

ANIMAL CODE

Enter one of the codes listed at the bottom of the column for all appropri≠ate animals.

IDENTIFICATION NUMBER

Record permanent identification, e.g., metal eartags 

and tattoos. If more than one is present, record them 

all. If none is present, apply metal eartag and record 

that number.

AGE Record the age in years.

BREED

Use the two-digit breed codes listed in table 3.

SEX Enter M (male), F (female), or N (neuter).

RESULTS

Record the diameter of the indurated area in millimeters in the fi rst col≠umn. Record the result of the test in 

the second column: N (negative) or S (suspect).

REACTOR TAG NUMBER

If reactors are present, record the reactor tag 

number applied.

DATE, OWNER’S SIGNATURE

Have the owner sign and date the form. Leave part 3 

(third sheet of the form) with the owner.

THIS AUTHORIZATION TO TEST EXPIRES

Enter the date. It is determined by each State and may 

vary depending on the circumstances. Check with your 

State Veterinarian’s office.

After completing the form, send parts 1, 2, and 5 to the 

State or Veterinary Services area office (check with your 

State), give part 3 to the owner, and keep part 4 for 

your records.
16–17

SAMPLE
16–18

SAMPLE
16–19

SAMPLE
16-20

VS FORM 10-4 INSTRUCTIONS

ALL information must be printed legibly or typed. Use a separate form for each species and owner. 

At the minimum, complete all fields designated in these instructions as required. Contact the 

Receiving Department of the laboratory to which you are sending specimens with specific 

documentation or shipping questions. If including more than one page, include the page number of 

total pages submitted (e.g., 1 of 3).

1. SUBMITTER CONTACT INFORMATION “REQUIRED”

Enter the submitter’s business name/affiliation; the name of the individual submitter is optional if 

test results are returned to a general business fax, email, or mailing address. Enter a fax number or 

email address to which we can return test results. Multiple email addresses are permissible. Specify 

if there is a preferred method of report delivery; email will be used if no preference is stated. 

Provide a complete mailing address. If fax or email is not available, test reports can be mailed, but 

this will delay delivery of your results. Repeat submitters are encouraged to be consistent with the 

submitter contact information that they provide, as the NVSL keeps a master record. If the test 

report for an individual submission needs to be routed to a non-standard destination, include 

special instructions in Block 22, Additional Data.

2. NVSL SUBMITTER ID

For more efficient service, repeat submitters are encouraged to include their NVSL Submitter ID. If 

you do not know your ID, contact the NVSL at (515) 337-7514.

3. OWNER INFORMATION “REQUIRED”

Enter the complete name of the animal owner, the city and the two-letter abbreviation of the State 

in which the owner resides. Ensure the animal owner is identified here and not the property 

manager or veterinarian. For wildlife, check the box to indicate there is no owner.

4. LOCATION OF THE ANIMALS “REQUIRED”

Include National Animal Identification System (NAIS) premises ID if available. Also, specify the 

county, parish or other designated location of the animals and the two-letter State abbreviation.

5. PAYMENT METHOD “REQUIRED FOR BILLABLE CASES”

Check the appropriate payment method. If payment is by user account or credit card, enter the 

account number. Enter the expiration month and year when using a credit card. Refer to the User 

Fees/Payment Options and the Catalog of Services/Fees, both located at

www.aphis.usda.gov/animal_health/lab_info_services/diagnos_tests.shtml, for

specific test fees and a list of accepted credit cards. DO NOT SEND CASH.

6. HERD/FLOCK SIZE

Enter the total number of animals in the herd/flock.

7. NO. IN HERD/FLOCK AFFECTED

Enter the total number of animals in direct contact with suspect animal or showing clinical signs.
16-21

8. NO. IN HERD/FLOCK DEAD

Enter the total number of animals from this herd/flock that are dead.

9. EXAMINATIONS REQUESTED “REQUIRED”

For disease programs, it is necessary only to enter the program name (e.g., CWD, Scrapie, or BSE). If 

the test is not for a disease program, specify the

disease and the desired test.

10. COLLECTED BY

Enter the complete name of the person collecting the specimen(s).

11. DATE COLLECTED

Enter the date on which specimens were collected. Use the format DD/MM/YYYY.

12. AUTHORIZED BY

Enter the name of the person authorizing the submission of this sample. Normally, this is the Area 

Veterinarian in Charge (AVIC) in your State. Authorization is assumed for regulatory veterinarians 

making routine program specimen submissions. See

http://www.aphis.usda.gov/animal_health/area_offices/ to locate the AVIC in your local area.

If an exotic (foreign) disease is suspected, contact the AVIC and the Emergency Programs staff to 

obtain authorization to submit samples for FAD testing and an investigation control number that 

must be included with the submission. DO NOT ship any such specimens until approval is received 

and a control number is assigned. The receipt of an unauthorized shipment of specimens containing

exotic disease agents can cause substantial disruption of work at the laboratory and result in 

possible fines for the submitter.

13. PURPOSE OF SUBMISSION “REQUIRED”

Definitions of Diagnostic Case Categories are as follows:

• Interstate Movement – Tests conducted for the purpose of qualifying live animals or poultry 

for interstate movement.

• Export – Tests conducted for the purpose of qualifying animals or poultry, including wild 

animals and birds, or animal or poultry products for export from the U.S. to a foreign 

country.

• Pre-Import – Tests conducted for the purpose of qualifying animals or poultry, including 

wild animals and birds, or animal or poultry products for import into the U.S. Select this 

purpose when the animals or products have not yet been moved into the U.S.

• Import – Tests conducted for the same purpose as pre-import except that the animals or 

products are currently located at a U.S. import center.

• FAD/EP Diagnostic – Tests conducted for the purpose of diagnosing or confirming a foreign 

disease, or for the eradication of a foreign disease that has gained entrance into the U.S. If a 

foreign animal disease is suspected, follow instructions in Block 12 for authorization to 

submit a FAD specimen.
16-22

• Surveillance – Tests conducted for monitoring for a specific disease, for a specific insect or 

insect vector, or for analyzing specific products that are used in treating animals or poultry 

or for decontamination of animal poultry facilities.

• TB – Tests conducted for diagnosing Tuberculosis.

• General Diagnostic Case – Tests conducted for the purpose of diagnosing or confirming a 

domestic disease, and/or the analysis of environmental products that may be contributing 

to an existing disease condition. Use this purpose when the purposes listed above do not 

apply.

• Developmental/Research – Tests conducted for the purpose of supporting a developmental 

or research project conducted by staff or field personnel of VS or by other laboratories, 

institutions, or agencies.

• Reagent Evaluation – Tests conducted for the purpose of evaluating a reagent produced by 

other laboratories, institutions, or agencies.

• NVSL Intralab – Tests conducted for another laboratory of the NVSL.

14. COUNTRY OF ORIGIN/DESTINATION

For import or pre-import cases, enter the country in which the animals last resided. For export 

cases, enter the country to which the animals will be shipped.

15. REFERRAL NUMBER

This number is typically assigned by the submitter and is used for the submitter’s own reference. In 

FAD cases, enter the investigation control number described in the instructions for Block 12.

16. PRESERVATION

Check all blocks that apply.

17. SPECIMENS SUBMITTED “REQUIRED”

Check all blocks that apply.

18. TOTAL NUMBER OF SPECIMENS SUBMITTED

Enter the total number of specimens submitted. Specimens in one container are counted as one 

sample. Please limit to <250 samples per submission.

19. SPECIES OR SOURCE “REQUIRED”

Check only one block. If specimens are from different species or sources, use a separate VS Form 

10-4 for each source. Reminder: Enter the animal BREED in Block 21.

20. NUMBER OF ANIMALS SAMPLED

Enter the total number of animals sampled.
16-23

21. IDENTIFICATION “REQUIRED”

• Sample ID – Identify samples with consecutive numbers. Ensure the sample identification 

number on this form matches the sample identification number placed on the 

specimen container.

• Animal ID – Record the animal’s national identification tag number adjacent to the 

appropriate sample number. If there is no national animal ID, record the most appropriate 

identification number (or name). NOTE: Laboratory results will be reported by animal 

identification number.

• Breed – Enter the animal breed (e.g., Holstein, Angus).

• Age – Indicate the approximate age in years (y), months (m), weeks (w), or days (d).

• Sex – Indicate the sex, male (M), or female (F), for each animal.

22. ADDITIONAL DATA

Enter all pertinent information about the animals and premises that can assist the lab in making a 

diagnosis.

• Provide detail on tissue specimens you are including (e.g., lymph nodes, obex, brain) 

• Specify clinical signs (e.g., weight loss, hair missing) 

• If meat is being retained pending specimen results, enter RETAINED

• Add related case submission numbers to assist in trace activities

• Include any information that did not fit into its designated space elsewhere on the form

• Include any special (non-standard) instructions for test report delivery

23. SIGNATURE OF SUBMITTER AND DATE

The individual submitting the specimen(s) must sign and date the form.
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 0579-0090, 0101, and 0212. The time required to complete this information collection 

is estimated to average .5 hours per response for 0579-0090, 1 hour per response for 0579-0101, and .333 hours per response for 0579-0212, 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 

0579-0090, 0579-0101, 

and 0579-0212 

INSTRUCTIONS: Use a separate form for each species and each owner/broker. See “Instructions for Completing VS Form 10-4” for definitions. 

UNITED STATES DEPARTMENT OF AGRICULTURE 

ANIMAL AND PLANT HEALTH INSPECTION SERVICE 

NATIONAL VETERINARY SERVICES LABORATORIES 

P.O. BOX 844, 1920 DAYTON AVENUE, AMES, IA 50010 

(515) 337-7514 

SPECIMEN SUBMISSION 

PAGE 

 OF 

1. SUBMITTER NAME (including Business Name) 2. NVSL SUBMITTER ID 3. NAME OF OWNER Check if wildlife (no owner) 

EMAIL ADDRESS OWNER CITY STATE/COUNTRY 

PHONE NO. FAX NO. 4. LOCATION OF ANIMALS 

MAILING ADDRESS (Street, City, State, ZIP Code) PREMISES ID 

COUNTY STATE/COUNTRY 

5. PAYMENT METHOD 

 USER FEE ACCOUNT NO. CHECK/MONEY ORDER 

 (Enclosed, payable to USDA in US dollars) 

 Number: 

CREDIT 

CARD Exp. Date: 

6. HERD/FLOCK SIZE 10. COLLECTED BY 

7. NO. IN HERD/FLOCK 

AFFECTED 

11. DATE COLLECTED 

8. NO. IN HERD/FLOCK 

DEAD 

9. EXAMINATIONS REQUESTED 

12. AUTHORIZED BY 

13. PURPOSE OF SUBMISSION (See instructions for definitions) 14. COUNTRY OF ORIGIN/DESTINATION 

 Interstate Movement Import TB Reagent Evaluation 

 Export FAD/EP Diagnostic General Diagnostic NVSL Intralab 

 Pre-Import Surveillance Developmental Research 

15. REFERRAL NUMBER 

 16. PRESERVATION 

 None Ice Pack Dry Ice Formalin Borax Alcohol Other (Specify) 

17. SPECIMENS SUBMITTED (“X” applicable item(s)) 

 Blood Feces Parasite Serum Tissue (specify) Whole Animal Other (specify) 

 Culture Feed Plant Soil Urine Fetus 

 Extract Milk Semen Swab (specify) Water DNA/RNA 

18. TOTAL NUMBER OF 

SPECIMENS SUBMITTED 

19. SPECIES OR SOURCE (“X” ONLY one) 

 Cattle Goat Chicken Bison Fish 

 Swine Horse Turkey Deer (specify) Environment 

 Sheep Donkey Other bird (specify) Elk Reagent 

 Other (specify) 

20. NUMBER OF ANIMALS 

SAMPLED 

21. IDENTIFICATION (See instructions <250 samples per form) IDENTIFICATION 

Sample ID Animal ID Breed Age Sex Sample ID Animal ID Breed Age Sex 

 

 

 

 

 

22. ADDITIONAL DATA (History, clinical signs, post mortem findings, remarks, tentative diagnosis, special instructions. Use additional sheets if necessary). 

23. SIGNATURE OF SUBMITTER AND DATE 

X 

NVSL USE ONLY 

CONDITION PRIORITY DISTRIBUTION RECEIVED BY 

NVSL USE ONLY 

VS FORM 10-4 

AUG 2009 

16-24 SAMPLE
16-25

VS Form 10-4 and 10-4A - Item 21 - Identification

Identify Samples with Consecutive Numbers - Record animal identification (number or name) 

adjacent to appropriate sample number. Laboratory results will be reported by sample 

identification number. You should therefore keep a copy of your submission so you will know the 

results for the appropriate animal.

Indicate approximate age in years (Y), months (M), weeks (W), or days (D), and indicate sex of each 

animal (M/F). When more than 10 samples are submitted, use VS Form 10-4A for samples # 11 on. 

See example sample below. 

Sample Animal Age Sex Sample Animal Age Sex

1 12ABC0001 5Y F 6 12ABC0006 10D F

2 12ABC0002 2Y M 7 12ABC0007 12M F

3 12ABC0003 1Y F 8 12ABC0008 8M M

4 12ABC0004 6M F 9 12ABC0009 2Y F

5 12ABC0005 5W M 10 12ABC0010 15M M
21. IDENTIFICATION (See instructions) IDENTIFICATION 

Sample ID Animal ID Breed Age Sex Sample ID Animal ID Breed Age Sex 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VS FORM 10-4A 

AUG 2009 

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 0579-0090, 0101, and 

0212. The time required to complete this information collection is estimated to average .5 hours per response for 0579-0090 1 hour per response for 

0579-0101, and .333 hours per response for 0579-0212, 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 

0579-0090, 0579-0101, 

and 0579-0212

UNITED STATES DEPARTMENT OF AGRICULTURE 

ANIMAL AND PLANT HEALTH INSPECTION SERVICE 

VETERINARY SERVICES 

CONTINUATION SHEET FOR SPECIMEN SUBMISSION 

INSTRUCTIONS: Use this form only as a 

continuation of information on VS Form 

10-4 see “Instructions for completing VS 

Form 10-4”.

PAGE: 

 OF 

3. NAME OF OWNER/BROKER Check if wildlife (no owner) 

OWNER CITY OWNER STATE/COUNTRY 

15. REFERRAL NUMBER 

16-26 SAMPLE
16–29

SAMPLE
16–30

SAMPLE
16-31

VS Form 10 – 12: Equine Infectious Anemia Supplemental 

Investigation

CASE ID: Self-explanatory.

LAB ACCESSION NO.: Self-explanatory.

INVESTIGATOR’S NAME: Investigator’s name and telephone number.

INVESTIGATOR’S AFFILIATION: Self-explanatory.

INVESTIGATION DATE: Self-explanatory.

OWNER’S LOCATION: Enter complete name, address, and telephone number of the owner’s 

location.

NAME OF CONTACT PERSON: Enter the complete name, address, and telephone number of the 

local contact person (e.g., the stable manager).

All remaining blocks on this form are self-explanatory. 
16–32

VS Form 10 – 13: Owner/Shipper Certifi cate: Fitness to Travel to a 

Slaughter Facility

TIME HORSES LOADED ON CONVEYANCE

Enter the exact time horse(s) was/were loaded onto a 

truck, tractor, trailer, or semitrailers or any combination 

of these, propelled or drawn by mechanical power. Indicate time as AM, PM, or Military time.

DATE

The date you are completing this form 

(day, month, year).

VEHICLE LICENSE NO. AND DRIVER’S NAME

The vehicle license number is the tag number of the 

conveyance. Enter the name of the person who is 

actually driving the conveyance.

CONSIGNOR (OWNER/SHIPPER) NAME

Enter the name of any individual, partnership, 

corporation, or cooperative association that engages in 

commercial transportation of more than 20 equines per 

year to slaughtering facilities.

The three blocks immediately below refer to the street 

address, city/State/ZIP code, and phone number of the 

owner/shipper.

CITY AND STATE WHERE HORSES WERE LOADED 

ON CONVEYANCE

Enter the complete city and State where the horse(s) 

were loaded onto a truck, tractor, trailer, or semitrailer 

or any combination of these, propelled or drawn by 

mechanical power.

NAME OF AUCTION/MARKET

If the owner/shipper purchased any horse(s) from 

an auction or livestock market, provide the name of 

the facility.

CONSIGNOR (RECEIVER/DESTINATION) NAME

Enter the name of the person and/or slaughter plant 

that is taking receipt of the Horse(s) at its/their fi nal 

destination. 

The three blocks immediately below refer to the street 

address, city/State/ZIP code, and phone number of the 

person and/or slaughter plant receiving the animal(s).

CHECK THE BOX THAT INDICATES . . .

Check all the boxes beside statements that are true for 

all the horses traveling on this certificate.

Identifi cation Section

Fill out as completely as possible. The description 

MUST match each horse exactly; therefore, be precise 

when recording information.

TAG PREFIX

This information is located on the top of the green 

equine backtag. The alpha prefi x is USAA through ZZ. 

This prefix MUST be recorded as it is part of the backtag number.

Tag NO.

This information is located on the green equine backtag 

and is a 3- or 4-digit number. This number MUST be 

recorded.

COLOR DESCRIPTION

Of the six possible boxes, check the one that best describes each individual horse.

BREED/TYPE

Check the appropriate box. TB = thoroughbred; 

QT = quarter horse.

SEX

Check the appropriate box.

BRANDS Tattoos, etc.

Indicate any brands, tattoos, markings, or stars that 

would aid in identifying the individual horse(s).

REMARKS Include existing conditions

Fill in this section as completely as possible for 

each animal.

SIGNATURE

The driver of the conveyance signs here, certifying 

that the horses have been offered food and water and 

been allowed to rest as required under all applicable 

Federal laws.

SIGNATURE OF OWNER/SHIPPER

The owner/shipper signs here, certifying that all information on the form is true and correct.

CANADIAN FOOD INSPECTION AGENCY (CFIA)

Leave blank.
16–33

SAMPLE
16–34

VS Form 10 – 13A: Owner/Shipper Certifi cate: Fitness to Travel to a 

Slaughter Facility (Continuation Sheet)

This form furnishes additional lines to be filled in only 

when the number of animals being shipped exceeds 15. 

Note that the owner/shipper must also sign and date 

this sheet at the bottom and indicate that it is page 2 

of 2. If there are more than 45 horses in this shipment, 

additional Forms 10–13A may be used, but be sure to 

renumber the left-hand column, beginning with 46 to 

account for every animal individually.
16–35

SAMPLE
16–36

VS Form 17 – 6: Certifi cate for Poultry or Hatching Eggs for Export

Note: This form must be typed. 

DATE OF SHIPMENT

Self-explanatory. 

NAME AND ADDRESS OF EXPORTER

Use the complete name and mailing address of the 

exporter. The Federal Information Processing Standards 

(FIPS) State codes may be found on the reverse side of 

the bottom sheet of the carbon-pack form. 

NAME AND ADDRESS OF IMPORTER

Use the complete name and mailing address of the 

importer. Contact your Veterinary Services area offi ce 

for information regarding the FIPS country codes. 

QUANTITY/UNIT

List eggs by the dozen or hatched poultry by the 

individual bird. 

VARIETY, STRAIN OR TRADE NAME

This information may be obtained from the exporter. 

PRODUCT

Use a checkmark or “X” in the block that describes the 

item or animal. 

SEX

Use a checkmark or “X” in the block that describes 

the animals in each of the Variety/Strain/Trade name 

groups. “Straight run” means that the sex is unknown 

(the birds have not been sexed). 

TYPE (Intended use)

Determine whether the group of birds on a particular 

line are commercial production stock, multiplier breeding stock, or primary breeding stock. Then use a checkmark or “X” under the appropriate header to label the 

group as egg-type, meat-type, or “other.” 

NPIP APPROVAL

Fill in the appropriate number. 

NPIP CLASSIFICATION – U.S.

Use a checkmark or “X” to describe the entire group of 

birds on a particular line. 

TOTAL NUMBER OF UNITS CERTIFIED FOR EXPORT

Add either in dozens for eggs or individual numbers for 

hatched poultry. 

CHECK APPROPRIATE CERTIFICATION BELOW

Check A or B. 

REMARKS OR ADDITIONAL INFORMATION

Make additional remarks here if necessary. 

TYPED NAME OF ISSUING VETERINARIAN

Self-explanatory. 

SIGNATURE OF ISSUING VETERINARIAN

Sign the form only after it is completed. 

STATUS

Check the block that best describes your status. This 

certificate is official only if it is signed by an accredited, 

State, or Fed≠eral veterinarian. 

DATE ISSUED

Self-explanatory. 

SIGNATURE OF ENDORSING FEDERAL 

VETERINARIAN

Check with the Federal Area Veterinarian-in-Charge to 

fulfi ll this requirement. 

DATE ENDORSED

This block is completed only if the Federal Area 

Veterinarian-in-Charge signed in the preceding block.
16–37

SAMPLE
16-38

VS Form 17 – 140: United States Origin Health Certificate General Information and 

Navigation Hints

Begin by filling out the Consignor [shipper] and Consignee [receiver] information in blocks 1, 7, 8, 12, 13, 

14, and 16 (including DESTINATION COUNTRY and ENTER CODE blocks, which are not numbered 

themselves). Block-specific instructions follow where appropriate. Block 2 is not filled in by you; the 

form comes with a preprinted unique number on it, and we have erased that on purpose here. Block 3 

cannot be filled in until you know if you will need to use Form 17–140A, the continuation sheet for Form 

17–140. 

Next, fill in general information about this health certificate: insert the date on which you are issuing the 

certificate (block 4), the location where the shipment is leaving the United States (blocks 5 and 6), and the 

shipping method being employed (block 11). Indicate whether or not this shipment is of semen

(block 9) and if so, how many doses are being shipped (block 10).

Determine which non poultry SPECIES is being shipped (block 15). Check only ONE species and describe 

all such animals on this Form 17–140. If the shipment includes animals of other species, fill out a separate 

Form 17–140 for each species and check the appropriate species in block 15 on each form. [If the 

shipment includes poultry, do not use Form 17–140 for the poultry, use Form 17–6 instead.] 

Fill in the FARM ORIGIN information (block 17) as specified on the form itself. Then determine which 

types of tests you are certifying and complete the blocks on the central and right-hand parts of the form 

accordingly.

In the CERTIFICATION BY ISSUING VETERINARIAN section at the bottom of Form 17–140, you will give 

information about yourself in blocks 20 and 21, fill in the total number of animals on all sheets describing 

this shipment in block 22, and sign your name in block 25. Leave blocks 23 and 24 blank. The endorsing 

Federal veterinarian will complete blocks 23 and 24. 

Block-by-Block Instructions

PAGE NO. [block 3]

If all animals in this shipment can be described in the space on this form, enter “1 of 1” in block 3. If not, 

use Form 17–140A (Continuation Sheet for the United States Origin Health Certificate) to account for all 

animals being shipped and enter “1 of X” with “X” standing for the total number of forms involved.

DATE ISSUED [block 4]

Enter the date the veterinary inspection is completed. 

U.S. PORT OF EMBARKATION [block 5]

For an export by land to Canada or Mexico, enter the city and state of the US POE across from the 

Canadian or Mexican POE. For an export by air or sea, enter the city and state of the loading point for 

transportation to the airport or seaport, which would usually be the location where the animals were 

prepared for export. 

STATE CODE [block 6]

The two letter USPS code of the State for the port of embarkation listed in block 5. 

STATE CODE [block 13]

The two letter USPS code of the consignor’s State listed in block 12. 
16–39

SAMPLE
16–40

VS Form 17 – 140A: Continuation Sheet for United States Origin Health Certifi cate

Use this form only when the number of individually 

identified animals in a shipment exceeds 18, thus overfl owing the space available in blocks 17 and 18 of VS 

Form 17–140. 

The name in block 1 of this form is the same as the 

Consignor’s Name in block 1 of the corresponding 

Form 17–140. Likewise, the Consignee’s Name in block 

16 of this form is the same as that name in block 16 on 

the corresponding Form 17–140. 

In block 2, insert the preprinted certifi cate number 

from block 2 of the corresponding Form 17–140. Fill 

in the fi nal page count in block 3 (“2 of X” or “3 of X” 

with X standing for the total number of forms including all continuation sheets). 

The directions for blocks 17 and 18 are the same as for 

those blocks on the Form 17–140. No signatures are required on these continuation sheets.
16–41

SAMPLE
16-42

APHIS Form 7001: United States Interstate and International Certificate of Health

Examination for Small Animals

DATE OF THE FORM (Bottom left corner)

This form was revised in November 2010, so there are two versions in circulation, the August 1994 

version and the November 2010 version. The two major changes to the November 2010 version are that 

there is no owner certification/signature block and the veterinarian certification block has been modified. 

There are other changes to the information required. You may use either version of this form until the 

supply of the August 1994 version is used up or withdrawn. The 7001A continuation form is dated 

September 1983 and it should be used when needed with either the August 1994 or November 2010, 7001 

certificates.

TYPE OF ANIMAL SHIPPED

On this form, you may mix animals of different species. Check all species that apply to the current 

shipment.

CERTIFICATE NUMBER

Again, this number is preprinted on the official APHIS Form 7001. We have erased the form number in 

this example for security reasons.

TOTAL NUMBER OF ANIMALS

Self-explanatory. The PAGE block directly to the right of the total number of animals block refers to 

“Page 1 of X” where X indicates the continuation sheets (APHIS Form 7001A) that are attached with this 

Form 7001. If there are no continuation sheets just write ‘Page 1’. 

NAME, ADDRESS AND TELEPHONE NUMBER OF OWNER/CONSIGNOR

Self-explanatory. If the consignor is licensed or registered under the Animal Welfare Act, include his or 

her official USDA number. Insert his or her telephone number regardless of registration status. 

NAME, ADDRESS AND TELEPHONE NUMBER OF CONSIGNEE

Insert the shipper’s information here, including USDA license or registration number (if applicable) and 

phone number.

ANIMAL IDENTIFICATION

The owner or consignor (shipper) fills in this information. The owner or consignor also checks with an X 

both certification in the unnumbered block below line 10 of block 5 and signs and dates the form below 

those check-marked blocks.

VACCINATION HISTORY

You fill in this section. If rabies certificates are involved, attach them (showing your original signature, 

not a photocopy) at the black arrow on the right-hand side of the form.

VETERINARY CERTIFICATION

Check the block(s) that apply. Print your name, address and telephone number in the block provided and 

insert your license number and the name of the State where you received it (or your NAN if appropriate). 

Finally, sign at the bottom right and insert the date you examined the animals on this certificate.

ENDORSEMENT FOR INTERNATIONAL EXPORT [unnumbered block at the lower left corner of the 

form] 

If the animals on this shipment are being sent out of the United States, a USDA veterinarian must apply 

the USDA seal or stamp and sign and date this form 7001. 
16–43

SAMPLE
SAMPLE 16-44
16–45

SAMPLE
16-46

APHIS Form 7001A: United States Interstate and International Certificate of Health

Examination for Small Animals (Continuation Sheet)

Please note, the APHIS Form 7001 was revised in November 2010, so there are two versions in 

circulation, the August 1994 version and the November 2010 version. You may use either version of the 

APHIS FORM 7001 until the supply of the August 1994 version is used up or withdrawn. The 7001A 

continuation form is dated September 1983 and it should be used when needed with either the August 

1994 or November 2010, 7001 certificates.

CERTIFICATE NUMBER [block 1]

Insert by hand the preprinted certificate number from block 1 of the Form 7001 for which this 7001A is a 

continuation sheet.

PAGE [block 2]

Insert page 2 (or 3, etc.) of X, with X standing for the total number of sheets of Form 7001 and all 7001A 

forms for this entire shipment. 

NAME, ADDRESS AND TELEPHONE NUMBER OF OWNER/CONSIGNOR [block 3]

Transfer this information from block 3 of the Form 7001. You do not need to repeat the USDA license or

registration number. Do repeat the shipper’s telephone number, however.

NAME, ADDRESS AND TELEPHONE NUMBER OF CONSIGNEE [block 4]

Transfer this information from block 4 of the Form 7001. You do not need to repeat the USDA license or 

registration number. Do repeat the recipient’s telephone number, however. 

ANIMAL IDENTIFICATION [block 5, lines 11–31 as needed]

The owner or consignor (shipper) fills in this information. 

VACCINATION HISTORY [block 6]

You fill in this section. If rabies certificates are involved for the animals on this continuation sheet, attach 

them (showing your original signature, not a photocopy) at the black
16-47

VS Form 17-145: U. S. Origin Health Certificate for the Export of 

Horses from the United States to Canada

General Information and Navigation Hints

This Origin Health Certificate may be used for the permanent or temporary export of horses from 

the United States to Canada except for horses for immediate slaughter. VS Form 17-140 must be 

used for the export of immediate slaughter horses from the United States to Canada.

The markings on the legs are as viewed from the rear of the horse. Therefore the two legs on the left 

side of the form (marked Fore) are for marking the front legs as viewed from the rear of the horse. 

The two legs on the right side of the form (Marked Hind) are for marking the back legs as viewed 

from the rear of the horse.

The age of the horse may be listed in days, weeks, months, or years and the letters “d, w, m, y” 

should be added to the age number to clarify.

The endorsing Federal Veterinarian will add the Health Certificate Number when endorsed.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB number. The valid OMB control

number for this information collection is 0579-0032. The time required to complete this collection of information is estimated to average .266 hours per response, including the time

for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the form.

16-48 SAMPLE