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 0579-0047. The time required to complete this information collection is estimated to average .17 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

0579-0047

EXP: 01/2027

UNITED STATES DEPARTMENT OF AGRICULTURE 

ANIMAL AND PLANT HEALTH INSPECTION SERVICE 

VETERINARY SERVICES 

BRUCELLOSIS TEST RECORD 

MARKET CATTLE TESTING PROGRAM 

STATE 

SAMPLES DRAWN AT (“X” One) ESTAB. NO. 

LIVESTOCK MARKETS SLAUGHTER ESTAB. 

NAME AND ADDRESS OF PLACE WHERE SAMPLES WERE DRAWN 

CERTIFICATTION 

I CERTIFY THAT I HAVE COLLECTED AND CORRECTLY 

IDENTIFIED EACH BLOOD SAMPLE LISTED BELOW. 

 

 

 

 

 

 

 

 

 I 

I 

□ □ 

SIGNATURE 

DATE 

TESTING LABORATORY 

LABORATORY 

ADDRESS 

DATE 

SIGNATURE

TEST RESULTS 

NEG. 

SUS. 

REA. 

TOTAL 

TUBE NO. 

SALES 

TAG OR 

BRAND 

BACK TAG NO. EAR TAG NO.

VACC. 

TATTOO AGE

BREED

SEX 

LABORATORY RESULTS 

RAP BAPA Card FPA

∆mP 

CF OTHER

TEST 

IN 

TREP. HERD OWNER’S NAME ADDRESS

VS 4-54 Previous editions are obsolete. PAGE NO. MAY 2014
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Privacy Act Notice 

Veterinary Services – Brucellosis Information System and Brucellosis Recording and Reporting System 

Authority: 21 U.S.C. 111, 112, 114, 114a-1, 115, 120, 121, 125, 134a-134f and title 9, Code of Federal Regulations, part 51 and 

part 78. 

Purpose and Routine Uses: 

Routine uses of records maintained in the system, including categories of users and the purposes of such uses: 

1) Detecting the foci of infection to reduce the rate of spread of infection to new herds; 

2) Evaluating brucellosis program activities of State, Federal, and contractual personnel; 

3) Preparing mailing labels and preaddressed forms to enhance field activities; 

4) Evaluating program effectiveness; 

5) Detecting factors of epidemiologic importance in containing or eliminating foci of infected herds; 

6) Assuring that brucellosis indemnities are promptly and properly paid; 

7) Notification of livestock owners with the animals at high risk of exposure to brucellosis because of livestock movements or 

an outbreak of disease or presence of quarantined premises in a community; 

8) Referral to the appropriate agency, whether Federal, State, local, or foreign, charged with responsibility of investigating or 

prosecuting a violation of law concerning animal disease control and eradication, or of enforcing or implementing a 

statute, rule, regulation, or order issued pursuant thereto, of any record within this system when information available 

indicates a violation or potential violation of law concerning animal disease control and eradication, whether civil, criminal, 

or regulatory in nature, and either arising by general statute or particular program statute, or by rule, regulation, or court 

order issued pursuant thereto; 

9) Litigation by the Department of Justice 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 Department of Justice 

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 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 the 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; 

10) Use in a proceeding before a court or 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; and 

11) Response to a request from a congressional office from the record of an individual made at the request of that individual. 

To certain Federal and State animal health officials to conduct, analyze, and report on the progress of animal disease 

control or surveillance programs. 

Disclosure: Furnishing this information is voluntary; however, failure to furnish this information may impede brucellosis 

eradication activities.