Information Collection

State, Local, or Tribal Government

IC 184526 under ICR 201611-0579-005 · OMB 0579-0101.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0579-0101 can be found here:

2025-02-10 - No material or nonsubstantive change to a currently approved collection
2024-10-10 - No material or nonsubstantive change to a currently approved collection

Documents and Forms

Document Name Document Type
Form VS 5-18 State, Local, or Tribal Government Form
VS 5-18 Record of Animals Moved VS 5-18 Dec 2011.pdf www.aphis.usda.gov/library/forms/pdf/vs5_18.pdf Form
VS 5-19 FLOCK INSPECTION AND EPIDEMIOLOGY REPORT VS 5-19 DEC 2011.pdf Form
VS 5-19 D Scrapie Epidemiology Report VS 5-19D Feb 2011.pdf Form
VS 5-20 Individual Animal Information Report VS 5-20 DEC 2011.pdf Form
VS 1-23 Appraisal and Indemnity Claim Form REV VS 1-23 Sep 2010.pdf Form
VS 1-23 A Indemnity Worksheet - Owner/Company VS 1-23A-work May 2009.doc Form
VS 5-19C Scrapie PEMMP Inspection Report VS 5-19C Feb 2011.pdf Form
VS 5-29 Cooperative State - Scrapie Control Program VS 5-29 DEC 2011.pdf Form
Vs 5-29A Scrapie Test Record - Continuation Sheet VS 5-29A DEC 2011.pdf Form
VS 10-4 Specimen Submission VS 10-4 Aug 2009.doc www.aphis.usda.gov/library/forms/pdf/VS_Form10_4.pdf Form
Vs 5-19A Flock Inspection and Epidemiology Report Initial Flcok I REV VS 5-19A June 2013 Final.pdf Form
Vs 5-19b Flock Inspection and Epidemiology Report Flock Inspectio REV VS 5-19B June 2013 Final.pdf Form
VS 5-24 Application for Scrapie Classification, Classification R VS 5-24 Apr 2010.doc Form
VS 5-18A RECORD OF ANIMALS ACQUIRED VS 5-18A Dec 2011.pdf Form
VS 1-27 PERMIT FOR MOVEMENT OF RESTRICTED ANIMALS VS 1-27 JUL 2011.doc www.aphis.usda.gov/library/forms Form
VS 17-140 UNITED STATES ORIGIN HEALTH CERTIFICATE REV VS 17-140 NOV 2014.pdf www.aphis.usda.gov/library/forms Form
VS 5-21 AGREEMENT TO CONDUCT THE OFFICIAL HISTOPATHOLOGY VS 5-21 DEC 2011.docx Form
mou.pdf MOU IC Document
How to Create an On-Line CVI for AV.ppt How to Create an On-Line CVI for AV IC Document
Appendix A-1 FY 2010 Scrapie CA Guidance.docx Appendix A-1 FY 2010 Scrapie CA Guidance IC Document
Appendix A-2 Coop Agreement Award ASI 10-9100-1231.pdf Appendix A-2 Coop Agreement Award ASI 10-9100-1231 IC Document
Appendix A-3 NIAAGrant.pdf Appendix A-3 NIAAGrant IC Document
Appendix A-4_ MOU template for scrapie.doc Appendix A-4_ MOU template for scrapie IC Document
Appendix B_10-4 and 5-29 worksheets.docx Appendix B_10-4 and 5-29 worksheets IC Document
Appendices C-E screenshots.doc Appendices C-E screenshots IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	State, Local, or Tribal Government	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 9 CFR 54.2-54.21 and 79.2-79.6

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VS 5-18	Record of Animals Moved	VS 5-18 Dec 2011.pdf	http://www.aphis.usda.gov/library/forms/pdf/vs5_18.pdf	Yes	No	Printable Only
Form	VS 5-19	FLOCK INSPECTION AND EPIDEMIOLOGY REPORT	VS 5-19 DEC 2011.pdf		No		Paper Only
Form	VS 5-19 D	Scrapie Epidemiology Report	VS 5-19D Feb 2011.pdf		No		Paper Only
Form	VS 5-20	Individual Animal Information Report	VS 5-20 DEC 2011.pdf		No		Paper Only
Form	VS 1-23	Appraisal and Indemnity Claim Form	REV VS 1-23 Sep 2010.pdf		No		Paper Only
Form	VS 1-23 A	Indemnity Worksheet - Owner/Company	VS 1-23A-work May 2009.doc		No		Paper Only
Form	VS 5-19C	Scrapie PEMMP Inspection Report	VS 5-19C Feb 2011.pdf		No		Paper Only
Form	VS 5-29	Cooperative State - Scrapie Control Program	VS 5-29 DEC 2011.pdf		No		Paper Only
Form	Vs 5-29A	Scrapie Test Record - Continuation Sheet	VS 5-29A DEC 2011.pdf		No		Paper Only
Form	VS 10-4	Specimen Submission	VS 10-4 Aug 2009.doc	http://www.aphis.usda.gov/library/forms/pdf/VS_Form10_4.pdf	Yes	No	Printable Only
Form	Vs 5-19A	Flock Inspection and Epidemiology Report Initial Flcok Inspection for Complete Monitored Status in Scrapie Flock Certification Program	REV VS 5-19A June 2013 Final.pdf		No		Paper Only
Form	Vs 5-19b	Flock Inspection and Epidemiology Report Flock Inspection for Complete Monitored Status in the Scrapie Flock Certification Program	REV VS 5-19B June 2013 Final.pdf		No		Paper Only
Form	VS 5-24	Application for Scrapie Classification, Classification Renewal, or Reclassification of a State	VS 5-24 Apr 2010.doc		No		Paper Only
Form	VS 5-18A	RECORD OF ANIMALS ACQUIRED	VS 5-18A Dec 2011.pdf		No		Paper Only
Form	VS 1-27	PERMIT FOR MOVEMENT OF RESTRICTED ANIMALS	VS 1-27 JUL 2011.doc	http://www.aphis.usda.gov/library/forms	Yes	No	Printable Only
Form	VS 17-140	UNITED STATES ORIGIN HEALTH CERTIFICATE	REV VS 17-140 NOV 2014.pdf	http://www.aphis.usda.gov/library/forms	Yes	No	Printable Only
Form	VS 5-21	AGREEMENT TO CONDUCT THE OFFICIAL HISTOPATHOLOGY	VS 5-21 DEC 2011.docx		No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Natural Resources

Subfunction: Agricultural Innovation and Services

Privacy Act System of Records
Title: Animal Health Surveillance and Monitoring System	FR Citation: 76 FR 228

Number of Respondents: 66	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 25 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	990	990
Annual IC Time Burden (Hours)	62,539	62,539
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
MOU	mou.pdf	11/07/2012
How to Create an On-Line CVI for AV	How to Create an On-Line CVI for AV.ppt	11/15/2012
Appendix A-1 FY 2010 Scrapie CA Guidance	Appendix A-1 FY 2010 Scrapie CA Guidance.docx	11/15/2012
Appendix A-2 Coop Agreement Award ASI 10-9100-1231	Appendix A-2 Coop Agreement Award ASI 10-9100-1231.pdf	11/15/2012
Appendix A-3 NIAAGrant	Appendix A-3 NIAAGrant.pdf	11/15/2012
Appendix A-4_ MOU template for scrapie	Appendix A-4_ MOU template for scrapie.doc	11/15/2012
Appendix B_10-4 and 5-29 worksheets	Appendix B_10-4 and 5-29 worksheets.docx	11/15/2012
Appendices C-E screenshots	Appendices C-E screenshots.doc	11/15/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.