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 0579-0189. The time 

required to complete this information collection is estimated to average 20 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

0579-0189

EXP.: 08/2021

UNITED STATES DEPARTMENT OF AGRICULTURE

ANIMAL AND PLANT HEALTH INSPECTION SERVICE

VETERINARY SERVICES

APPLICATION FOR CHRONIC WASTING DISEASE HERD 

CERTIFICATION PROGRAM (CWD HCP) APPROVAL, RENEWAL, OR 

REINSTATEMENT OF A STATE

1. STATE 2. APPLICATION FOR (“X” one)

APPROVED STATUS

RENEWAL OF APPROVED STATUS

REINSTATEMENT OF APPROVED STATUS

3. REPORTING PERIOD

4. STATUS OF ACTION ITEMS IDENTIFIED ON THE LAST RENEWAL OR AS PART OF AN APPROVED STATE REVIEW

(Use an attachment sheet, if necessary)

5. QUALIFICATION (“X” all that apply)

A. The requirements of 9 CFR 55.23 (a) have been met. State CWD HCP regulations, program policies and standards, legal authorities, and other 

supporting documentation are attached. (The supporting documentation must describe which requirement(s) of 9 CFR 55.23 are being met.)

B. The CWD National Database OR an equivalent State database to maintain CWD HCP data is updated as needed and data are current, accurate, 

and complete for the reporting period.

C. The annual Approved State CWD HCP Report has been completed and submitted to the VS Regional Office.

6. INVENTORY OF ENROLLED HERDS

A. TOTAL NUMBER OF ENROLLED

DEER HERDS

B. TOTAL NUMBER OF

ENROLLED ELK HERDS

C. TOTAL NUMBER OF DEER

ENROLLED IN HCP

D. TOTAL NUMBER OF ELK

ENROLLED IN HCP

Comments (Note any mixed herds, etc.):

7. SURVEILLANCE ACTIVITIES

A. NUMBER OF ANIMALS TESTED

THROUGH ON-FARM SURVEILLANCE

B. NUMBER OF ANIMALS TESTED AT

SLAUGHTER

C. NUMBER OF ANIMALS TESTED AT HUNT

FACILITIES (SHOOTER OPERATIONS)

CERTIFICATION

Application and related documents have been submitted for review. Results of the completed review are indicated in block 14 below.

8. Signature of State Official 9. Type or Print Name 10. Date

11. Signature of Area Veterinarian in Charge 12. Type or Print Name 13. Date

14. Approval by VS Region

Application for Approved Status is complete and approved. Provisional Approved Status is approved.

Renewal of Approved Status is approved. Reinstatement of Approved Status is approved.

Form is being returned for completion or correction.

Renewal or Reinstatement of Approved Status is provisionally approved contingent on the conditions listed in the attachment being met by the

following date: ________________.

15. Signature of Regional Epidemiologist 16. Type or Print Name 17. Date

18. Veterinary Services hereby declares the above State Approved for the period beginning _______________ and ending ________________.

19. Signature of CWD Program Certifying Official 20. Type or Print Name 21. Date

VS FORM 11-2 

AUG 2012