OMB APPROVED NUMBER 0579-0278

United States Department of Agriculture 

Animal and Plant Health Inspection Services 

Veterinary Services

(USDA/APHIS/VS)

Department of Interior 

US Fish and WildlifeService

(DOI/USFWS)

Department of Commerce

National Oceanic and Atmospheric Administration 

National Marine Fisheries Service

(DOC/NOAA-Fisheries)

I. Identification

1. Genus/species (Latin Name): (Common Name):

2. Age (years): Unknown 0-1 >1 Brood

3. Total Net Weight (kg): (if known) Number (X1000): Lot Identification: Number of Containers in Consignment:

II. Place of Origin

1. Country/State: 2. Zone/Compartment:

3.

Aquaculture Establishment (Name and Address and Map Coordinates or GPS if known ):

III. Destination

1. Country/State: 2. Zone/Compartment:

3.

Aquaculture Establishment (Name and Address and Map Coordinates or GPS if known ):

IV. Declarations

Procedures for Aquatic Animal Health Inspections (AFS "Blue Book", current ed.), and which is officially recognized as being free from the pathogens or diseases

listed in the applicable table on the reverse side. 

ONLY ONE ENDORSEMENT IS NEEDED. STAMP APPLICABLE BOX BELOW AND CROSS OUT/INITIAL NON-APPLICABLE BOXES.

USDA/APHIS/VS *

(Farm raised aquatic livestock)

DOI/USFWS

(Freshwater public resource/feral aquatic animals)

DOC/NOAA-Fisheries

(Marine wildlife/feral aquatic animals, and aquatic 

animals in the Exclusive Economic Zone)

Accredited or Federal Veterinarian: Approved Aquatic Animal Inspector: Approved Aquatic Animal Inspector:

Name (print): Name (print) Name (print):

Signature Date Signature: Date: Signature: Date::

Endorsing Area Veterinarian in Charge: Address: Address:

Name (print):

Address:

Federal veterinarian (if applicable) Federal Veterinarian (if applicable)

Name (print) Name (print)

Signature: Date: Signature: Date: Signature: Date:

Stamp of Competent Authority: Stamp of Competent Authority: Stamp of Competent Authority:

VS FORM 17-141

(MAR 2006)

* USDA/APHIS/VS may, on request by DOI or DOC, endorse health certificates for non-farm raised aquatic animals

ANY ADDITIONAL INFORMATION OR SPECIFIC REQUIREMENTS OF IMPORTING COUNTRIES MAY BE ATTACHED TO THIS FORM 

IN AN ADDENDUM

Farmed/Aquaculture Stocks Public resource/Wild/Feral Stocks

Adult Juvenile Larvae Male Gametes Unfertilized eggs Fertilized eggs

HEALTH CERTIFICATE FOR THE EXPORT OF LIVE FINFISH, MOLLUSKS, AND CRUSTACEANS 

(AND THEIR GAMETES) PART 1 OF 2

NOTE: Mark all the relevant items with (X) in theappropriate space. CERTIFICATE NUMBER

The Competent Authority certifies that live aquatic animals or their gametes in the present consignment have as their place of production a Country Zone/Compartment 

Aquaculture establishment that has been subjected to an official health surveillance scheme according to the procedures described in the

OIE Diagnostic Manual for Aquatic Animal Diseases (current ed.), or USFWS/American Fisheries Society-Fish Health Section Standard

The undersigning representatives of the US Competent Authority attest that:

All samples from the present consignment used in determining the health status of the Country Zone/Compartment Aquaculture establishment 

were collected and tested in accordance with the procedures described in the OIE Diagnostic Manual for Aquatic Animal Diseases (current ed.), or

 USFWS/American Fisheries Society-Fish Health Section Standard Procedures for Aquatic Animal Health Inspections (AFS "Blue Book", current ed.), with negative results.
According to the Paperwork Reduction Act of 1985, no persons are required to re spond to a collection of information unless it displays a valid OMB number. Th e time to complete this collection of 

information is estimated to average .5 hours per response, including the time f or reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing 

and reviewing the form.

CERTIFICATE NUMBER: 

HEALTH CERTIFICATE FOR THE EXPORT OF LIVE FINFISH, MOLLUSKS, AND

CRUSTACEANS (AND THEIR GAMETES) PART 2 OF 2

Freedom from the diseases/pathogens listed below has been 

established for the areas denoted on the right

Country Zone Aquaculture Establishment

Yes No Yes No Yes No

Epizootic hematopoietic necrosis/EHNV

Infectious hematopoietic necrosis/IHNV

Infectious pancreatic necrosis/IPNV

Infectious salmon anemia/ISAV

Oncorhynchus masou virus disease/OMV

Viral hemorrhagic septicemia/VHSV

And any of the following if required by the importing zone

Spring viremia of carp/SVCV

EXPORT OF LIVE MOLLUSKS AND GAMETES

Freedom from the diseases/pathogens listed below has been 

established for the areas denoted on the right

Country Zone Aquaculture Establishment

Yes No Yes No Yes No

Bonamiosis (Bonamia ostreae, B. exitiosa)

Haplosporidiosis (Haplosporidium costale, H. nelsoni)

Marteiliosis (Marteilia refringens, M. sydney)

Mikrocytosis (Mikrocytos mackini, M. roughleyi)

Perkinsosis (Perkinsus marinus, P. olseni)

And any of the following if required by the importing zone

EXPORT OF LIVE CRUSTACEANS AND GAMETES

Freedom from the diseases/pathogens listed below has been 

established for the areas denoted on the right

Country Zone Aquaculture Establishment

Yes No Yes No Yes No

Taura syndrome/TSV

White spot disease/WSSV

Yellowhead disease/YHV

And any of the following if required by the importing zone

VS 17-141

(MAR 2006)

EXPORT OF LIVE FINFISH AND GAMETES