VS Form 1-36A

DEC 2013

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 0579-0297. The time required to complete this collection of information is estimated to average .5 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

 0579-0297

Exp. Date: 2/2016

UNITED STATES DEPARTMENT OF AGRICULTURE

ANIMAL AND PLANT HEALTH INSPECTION SERVICE

VETERINARY SERVICES 

NATIONAL VETERINARY ACCREDITATION PROGRAM

APPLICATION FORM

1. Initial Accreditation 

State: ______ License Number:___________________

2. Authorization in a new State

State: ______ License Number:___________________

3. Change Accreditation Category (Block 15 or 16) 4. Contact Information Change

5. Accreditation Renewal 6. Post-Revocation Re-Accreditation

7. Name of Veterinarian (Last, First, M, Suffix): Check if your name has changed. 8. Six-Digit National Accreditation Number:

 _____ _____ _____ _____ _____ _____

9. Other Names Used (e.g., Maiden Name): 10. Date of Birth: 11. School of Veterinary Medicine: 12. Year Graduated:

13. State where First Orientation Completed: 14. Are you interested in participating in State or Federal agricultural emergency response efforts? 

Yes No 

ACCREDITATION CATEGORY SELECTION select only one – Block 15 OR 16

15. Category I animals (includes canines, felines, amphibians/reptiles, 

furbearing animals, laboratory animals (rodents), and non-human primates)

Refer to Explanation of Codes Page

Practice Code(s): 3 4 8 9 (select up to two) 

Species Code(s): 1 2 12 16 17 (rodents) 18 

 (select up to four; this does not limit the number of Category I species upon which you may 

 perform accredited duties) 

Primary Medical Discipline: _______ 

Employment Type: _______ 

16. Category II animals (includes all animals)

Refer to Explanation of Codes Page

Practice Code(s): _______ _______ (list up to two) 

Species Code(s): _____ _____ ______ _____ (list up to four; this does not limit the 

number of species upon which you 

may perform accredited duties) 

Primary Medical Discipline: _______ 

Employment Type: _______ 

CONTACT INFORMATION

17. Home Mailing Address: 24. Name of Business:

25. Business Mailing Address:

18. City: 19. State: 20. ZIP Code: 26. City: 27. State: 28. ZIP Code:

21. County of Home Mailing Address: 29. County of Business Mailing Address:

22. Home Phone: 30. Business Phone:

23. Email Address: 31.Business FAX Number: 

32.Business Cell Phone Number:

33. May your business contact information be released to the public by the USDA? Yes No 

ACCREDITATION RENEWAL OR CHANGE OF ACCREDITATION CATEGORY – Complete only if block 3 or block 5 are selected.

Enter the module numbers, not names, of the APHIS approved supplemental training modules you have completed. 

Category I veterinarians: three modules; Category II veterinarians: six modules.

34. 

Module Number

35.

Course Type

36. 

Date Module 

Completed

By signing in block 37, I certify that the information contained in this form is true and correct to the best of my knowledge. I am able to perform the tasks listed in Title 9 Code of Federal Regulations (CFR) 

Part 161.1(g) for the accreditation category designated in Blocks 15 or 16. I have been given a copy of the Standards of Accredited Veterinarian Duties contained in Title 9 CFR Part 161.4, and I agree to 

conduct all activities as an accredited veterinarian in accordance with the Standards of Accredited Veterinarian Duties.

37. Signature of Veterinarian: 38. Date:

Signature of the Veterinarian-in-Charge and the State Animal Health Official appearing below denotes endorsement of the applicant for Initial Accreditation and/or Post-Revocation 

Re-Accreditation.

39. Signature of State Animal Health Official: 40. Date:

41. Signature of Veterinarian-in-Charge: 42. Date:
Instructions for Completing VS Form 1-36A, National Veterinary Accreditation Program (NVAP) Application.

Block 1. Initial Accreditation: Check this block if you are applying for

initial accreditation. Enter the two-letter State abbreviation and your 

complete veterinary license number for this State. Complete blocks 1, 7, 9

(if applicable), 10, 11, 12, 13, 14, 15/16, 17-33, 37, and 38.

Block 2. Authorization in a new State: Check this block if you are 

seeking authorization to perform accredited duties in an additional State. 

Enter the two-letter State abbreviation and your complete veterinary license 

number for this State. Complete blocks 2, 7, 8, 9 (if applicable) 10, 17-33, 

37, and 38.

Block 3. Change Accreditation Category: Check this block if you are 

changing your Accreditation Category. Complete blocks, 3, 7, 8, 10, 15/16,

and 34-38. 

Block 4. Contact Information Change: Check this block if you are

changing your contact information (e.g., name, address). Complete blocks 

4, 7, 8, 10, 37, 38, and the appropriate CONTACT INFORMATION fields.

Block 5. Accreditation Renewal: Check this block if you are renewing 

your accreditation. Complete blocks 5, 7, 8, 10, and 34-38. You may not 

apply for renewal prior to 6 months of your renewal date.

Block 6. Post -Revocation Reaccreditation: Check this block if your 

accreditation was revoked and you are applying for reaccreditation. 

Complete blocks 6, 7, 8, 10, 15/16, 17-33, 37, and 38.

Block 7. Name of Veterinarian: Enter your legal last name, first name and 

middle initial. (If this is a name change request, enter your new legal name 

in this block.) Check the block, if your name has changed and complete 

Block 9.

Block 8. Six-Digit National Accreditation No.: Enter the National 

Accreditation Number that you have been assigned.

Block 9. Other Names Used (e.g., Maiden Name): Enter other names 

used – for example, maiden name, nickname (this name should not be the 

same name as in block 7). 

Block 10. Date of Birth: Enter the two-digit month, two-digit day, and fourdigit year of your birth.

Block 11. School of Veterinary Medicine: Enter the name of the school 

of veterinary medicine from which you graduated. 

Block 12. Year Graduated: Enter your four-digit year of graduation from a 

school of veterinary medicine.

Block 13. State where Orientation Completed: Enter the two letter 

abbreviation of the State where core orientation was completed.

Block 14. Are you interested in participating in State or Federal 

agricultural emergency response efforts? Check “yes” or “no”, if you 

would like to be contacted to assist with agricultural emergency response 

efforts.

Category Selection

(Refer to Explanation of Codes)

Block 15. Category I: Check this block for authorization to only perform 

accredited duties on canines, felines, amphibians/reptiles, furbearing 

animals, laboratory animals (rodents), and/or non-human primates.

Block 16. Category II: Check this block for authorization to perform 

accredited duties on all animals.

Species Code(s): Enter up to four code(s) associated with the species with

which you most often expect to perform accredited duties. These entries do 

not limit the species on which you may perform accredited duties within 

your Accreditation Category.

Practice Code(s): Enter up to two code(s) which most clearly describes the 

species upon which you will perform accredited duties.

Primary Medical Discipline: Enter the number associated with the 

discipline that best describes your primary medical discipline.

Employment Type: Enter the number associated with your employment 

type.

Home Contact Information

Block 17. Home Mailing Address: Enter your complete home mailing 

address. This is the address that will be used by NVAP to communicate 

with you. 

Block 18. City: Enter the city of your home address.

Block 19. State: Enter the two-letter state abbreviation of your home 

address.

Block 20. ZIP Code: Enter the five- or nine-digit ZIP code of your home 

address.

Block 21. County of Home Mailing Address: Enter the county in which 

your home address is located. 

Block 22. Home Phone: Enter your 10-digit home phone number. 

Block 23. Email Address: Enter your email address. (NOTE: If you enter 

a shared email address, that information may be viewed by others.)

Business Contact Information

Block 24. Name of Business: Enter the name of the business where you 

work/practice. If you are self-employed without a specific business name, 

enter your name from Block 7. 

Block 25. Business Mailing Address: Enter complete business mailing 

address. If your home mailing address is your business mailing address, 

write “Same as home address.”

Block 26. City: Enter the city of your business address.

Block 27. State: Enter the two-letter state abbreviation of your business 

address.

Block 28. ZIP Code: Enter the five- or nine-digit ZIP code of your business 

address. 

Block 29. County of Business Mailing Address: Enter the county in 

which your business address is located. 

Block 30. Business Phone Number: Enter your 10-digit business phone 

number.

Block 31. Business Cell Number: Enter your 10-digit cell phone number.

Block 32. Business FAX Number: Enter your 10-digit fax number. 

Block 33. May your business contact information be released to the 

public by the USDA? Check "yes" or "no" to having your business 

contact information released.

Block 34. Module Number: Enter the module numbers, not the names, of

the APHIS approved supplemental training modules you have completed.

Category I veterinarians: three modules; Category II veterinarians: six

modules

Block 35. Course Type: Enter either Online, Lecture, CD, or Print. The 

CD and Print designations indicate that you purchased a CD or printed 

version of the module from the Center for Food Security and Public Health

at Iowa State University.

Block 36. Date Module Completed: Enter the two-digit month, two-digit

day, and four-digit year that you completed the module.

Certification/Approval

Block 37. Signature of Veterinarian: Read the certification statement

above block 37 and sign in blue or black ink. (NOTE: The applicant MUST

be licensed or legally able to practice as a veterinarian.)

Block 38. Date: Enter the two-digit month, two-digit day, and four-digit

year that you signed this application.

Blocks 39-42: Do not enter any information in these blocks.

VS Form 1-36A

DEC 2013
PRIVACY ACT NOTICE

General:

This information is provided pursuant to Public Law 95-3579 (Privacy Act of 1974) December 31, 1974, for individuals completing the VS 1-36A.

Authority:

5 U.S.C. 3301, 7 U.S.C. 8309, and 21 U.S.C. 113a 

Routine Uses:

The information will be used for (1) Referral to State Animal Health officials to certify accreditation status or to exchange information regarding disciplinary action(s). (2) 

Referral to state veterinary examining boards to certify accreditation status or to exchange information regarding disciplinary action(s). (3) Disclosure to the public for the 

purpose of locating and contacting accredited veterinarians for a specific geographical location. (4) Referral to the appropriate agency, whether Federal, State, local or 

foreign, charged with the responsibility of investigating or prosecuting a violation of law, or of enforcing or implementing a statute, rule, regulation or order issued pursuant 

there to, of any record within this system when information available indicates a violation or potential violation of law, whether civil, criminal or regulatory in nature, and 

whatever arising by general statue or particular program statue, or by rule, regulation or order issued pursuant thereto. (5) Disclosure to the Department of Justice has 

agreed to represent the employee or the United States, where the agency determined that litigation is likely to affect the agency or any of its components, is a party to litigation 

or has an interest in such litigation and the use of such records by the Department of Justice is deemed by the agency to be relevant and necessary to the litigation ; provided, 

however, that in each case the agency determines that disclosure of the records to be Department of Justice is a use of the information contained in the records that is 

compatible with the purpose for which the records were collected. (6) Disclosure in a proceeding before a court of adjudicative body before which the agency is authorized to 

appear, when the agency, or any component thereof, or any employee of the agency in his or her official capacity, or any employee of the agency in his or her individual 

capacity where the agency has agreed to represent the employee or the United States, where the agency determines that litigation is likely to affect the agency or any of its 

components, is a party to litigation or has an interest in such litigation, and the agency determines that use of such records is relevant and necessary to the litigation; provided, 

however, that in each case the agency determines that disclosure of the records to the court is a use of the information contained in the records that is compatible with the 

purpose for which the records were collected (7) Disclosure to appropriate agencies, entities, and persons when the agency suspects or has confirmed that the security or

confidentiality of information in the system of records has been compromised; the agency has determined that as a result of the suspected or confirmed compromise there is a 

risk of harm to economic or property interests, a risk of identity theft or fraud, or a risk of harm to the security or integrity of this system or other systems or programs (whether 

maintained by the agency or another agency or entity) that rely upon the compromised information; and the disclosure made to such agencies, entities, and persons is 

reasonably necessary to assist in connection with the agency’s efforts to respond to the suspected or confirmed compromise and prevent, minimize, or remedy such harm; (8) 

Disclosure to cooperative Federal, State, and local government officials, employees, or contractors, and other parties engaged to assist in administering the program. Such 

contractors and other parties will be bound by the nondisclosure provisions of the Privacy Act. This routine use assists the agency in carrying out the program, and thus is 

compatible with the purpose for which the records are created and maintained. (9) Disclosure to USDA contractors, partner agency employees or contractors, or private 

industry employed to identify patterns, trends or anomalies indicative of fraud, waste, or abuse. (10) Disclosure to the National Archives and Records Administration or to the 

General Services Administration for records management inspections conducted under 44 U.S.C. 2904 and 2906. 

Effects of Nondisclosure:

Although this information is voluntary, failure to complete all the information may delay the process of the application or it may result in the application not being processed. 

VS Form 1-36A

DEC 2013
Explanation of Codes 

Practice Codes (Blocks 15 & 16)

(May indicate up to 2 codes)

(“Predominant” = Greater than 50% 

Species Contact,

“Exclusive” = Only Species Contact)

1 - Food Animal Predominant

2 - Food Animal Exclusive

3 - Companion Animal Predominant

4 - Companion Animal Exclusive 

5 - Mixed Animal

6 - Equine Predominant

7 - Equine Exclusive

8 - Other

9 - No Species Contact

Species Codes (Blocks 15 & 16) 

 (May choose up to 4 codes)

1 - Canine

2 - Feline

3 - Equine

4 - Bovine

5 - Porcine

6 - Ovine/Caprine 

7 - Camelid

8 - Cervid

9 - Poultry

10 - Avian (non-poultry)

11 - Exotics

12 - Amphibian/Reptile

13 - Aquatic Animal

14 - Zoo Animal

15 - Wildlife

16 - Furbearing Animals

17 - Laboratory Animal

18 - Non-Human Primate

19 - Other Species

20 - No Species Contact

Primary Medical Disciplines 

(Blocks 15 & 16) 

(Choose only 1 discipline)

1 - Anatomy

2 - Anesthesiology

3 - Animal Behavior

4 - Animal Welfare

5 - Alternative/Contemporary

6 - Association Management

7 - Biochemistry

8 - Biomedical Engineering

9 - Business/Economics

10 - Cardiology

11 - Dentistry

12 - Dermatology

13 - Disaster Medicine

14 - Ecology

15 - Emergency and Critical Care

16 - Endocrinology

17 - Environmental Health

18 - Epidemiology

19 - Ethics

20 - General Medicine

21 - Genetics

22 - Human Animals Bond

23 - Homeland Security

24 - Immunology

25 - Internal Medicine

26 - Insurance

27 - Laboratory Animal Medicine

28 - Law

29 - Media

30 - Microbiology

31 - Mycology/Bacteriology

32 - Molecular Biology

33 - Neurology

34 - Non-Medical

35 - Nutrition

36 - Oncology

37 - Ophthalmology

38 - Parasitology

39 - Pathology - Anatomic

40 - Pathology – Clinical

41 - Pharmacology

42 - Pharmacology – Clinical

43 - Physiology

44 - Population Medicine

45 - Poultry Medicine

46 - Preventative Medicine

47 - Production Medicine

48 - Public Health

49 - Radiology

50 - Shelter Medicine

51 - Sports Medicine

52 - Surgery

53 - Theriogenology

54 - Toxicology

55 - Virology

56 - Wildlife Medicine

57 - Zoological Medicine

58 - Other Professional Discipline

Employment Type (Blocks 15 & 16) 

(May choose only 1 type) 

Private Clinical Practice

1 - General Medicine/Surgery

2 - Production Medicine

3 - Referral/Specialty Medicine

4 - Emergency/Critical Care Medicine

5 - Other Private Clinical Practice

Academia

6 - Veterinary Medical College/School

7 - Veterinary Science Department

8 - Veterinary Technician Program

9 - Animal Science Department

10 - Other Academia

Government

11 - U.S. Federal

12 - State

13 - Local

14 - Foreign

15 - Army

16 - Air Force

17 - Public Health Commission Corps

18 - Other Government

Industry/Commercial

19 - Pharmaceutical/Biological

20 - Feeds/Nutrition

21 - Laboratory

22 - Agriculture/Livestock Production

23 - Business/Consulting Services

24 - Other Industry/Commercial

Other

25 - Humane Organization

26 - Membership Assn/Professional 

Society

27 - Foundation/Charitable Organization

28 - Missionary/Service

29 - Zoo/Aquarium

30 - Wildlife

32 - Temp Not Employment in Veterinary 

Field

33 - Non-Veterinary Employment

34 - Not Employed

35 - Not Listed Above

This Professional Classification System is used courtesy of the American Veterinary Medical Association.

VS Form 1-36A

DEC 2013