Form VS 4-28 VS 4-28 Application for Herd Entry/Renewal into the VBJDCP

According to the Paperwork Reduction Act of 1995, no persons are required to re spond to a collection of information unless it displays a valid OMB control num ber. The
valid OMB control number for this information collection is 0579 XXXX. The tim e required to complete this information collection is estimated to average .250 hours per
response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and review ing the
collection of information.

U.S. DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES

FORM APPROVED
OMB NUMBER
0579-XXXX

APPLICATION FOR HERD ENTRY/RENEWAL INTO THE
VOLUNTARY BOVINE JOHNE'S DISEASE CONTROL PROGRAM

FARM NAME:

FARM ADDRESS:

OWNER/MANAGER NAME:

PHONE NUMBER:

FARM/PREMISES ID NUMBER:

I wish to enroll my herd as Johne's Program (JP):
Management

JP Level A

Testing Type Performed: My herd was tested on:

This Application is for:

JP Level 1

Enrollment

Number tested:

Advancement

VETERINARIAN'S NAME:

JP Level 2
JP Level B
Number test positive results:

JP Level 3

JP Level 4

JP Level C

JP Level D

Number of test eligible animals in herd (3 yrs of age and older):

Monitoring

Please attach a copy of the relevant laboratory results and a copy of your herd management plan with this application.
I am willing to have my herd listed in the public register of herds, attaining or maintaining the indicated program level for the indicated cattle type. I understand that public
registration may include listing on a website, printed material, and other forms of media.
Yes
No
Cattle Type:

Dairy

Beef

Mixed Breed

A copy of the Voluntary Bovine Johne's Disease Control Program Producer Guidelines has been supplied to me and I agree to comply with the program guidelines. I certify
that to the best of my knowledge, all the information provided on this form is accurate.
Owner/Manager Signature:

VS 4-28
(JUN 2007)

Date:

INSTRUCTIONS FOR THE APPLICATION FOR HERD ENTRY/RENEWAL INTO VOLUNTARY BOVINE JOHNE'S DISEASE CONTROL PROGRAM
The purpose of these instructions is to outline the Voluntary Bovine Johne's Disease Control Program (VBJDCP) applications for Herd Entry/Renewal into the program. The
major objective is to pro vide uniformity in recording official applications for Herd Entry/Renewal into the program, and to facilitate the recording of statistical information so
that it ill be readily available for program evaluation.
Farm Name - The name in which the owner does business with that identifies the premises. Owner's/Manager Name - The owner's/manager's owner's last name, first
name, and middle initial, should be printed or legibly written. Farm Address - Fill in the complete farm address, include the mailing address if it is differe nt from the farm
address. Phone - The number to where the owner/manager can be reached. Farm/Premises ID Number - The code number for the Herd, Farm, Ranch, Dairy, or premises
ID is to be recorded in this block by the states that are maintaining a master identification file. Veterinarian's Name - Name of licensed veterinarian employed by the owner
to assist in maintaining animal(s) health.
JOHNE'S DISEASE PROGRAM (JP) LEVELS
Management - Check this box if the herd owner has completed a risk assessment and a herd management plan but does not wish to be classified as a test positive or test
negative herd.
JP Level 1 - Check this box if the herd owner has completed a risk assessment and a herd management plan and the herd is tested with an approved test strategy for Level
1 and the herd or any animals were not classified as infected.
JP Level 2 - Check this box if the herd owner has completed a risk assessment and a herd management plan and the herd is tested with an approved test strateg y for Level
2 and the herd or any animals were not classified as infected.
JP Level 3 - Check this box if the herd owner has completed a risk assessment and a herd management plan and the herd is tested with an approved test strate gy for Level
3 and the herd or any animals were not classified as infected.
JP Level 4 - Check this box if the herd owner has completed a risk assessment and a herd management plan and the herd is tested with an approved test strateg y for Level
4 and the herd or any animals were not classified as infected.
JP Level A - Check this box if the herd has completed a risk assessment and a herd management plan and the herd or any animals were not found test positive bu t the herd
is not applying for a program levels 1-4.
JP Level B - Check this box if the herd has completed a risk assessment and a herd management plan and testing the whole herd indicated a prevalence rate less than 5%.
JP Level C - Check this box if the herd has completed a risk assessment and a herd management plan and testing the whole herd indicated a prevalence rate betw een 5%
and 15%.
JP Level D - Check this box if the herd has completed a risk assessment and a herd management plan and testing the whole herd indicated a prevalence rate grea ter than
15% or if less than the whole herd was tested, any positive test results were found.
Testing performed-write in the type of testing (serum ELISA, fecal culture, environmental, fecal pooling, etc.) that was done if JP Level 1-4 or JP Level A-D, is being sought
Herd Test Results-Tested: This space is provided to show the date the tested was completed, number of animals tested and the number of animals that tested po sitive for
Johne's Disease.
Type of Application for Herd Entry: Enrollment, Advancement, and Monitoring. Enrollment - Check this box if this is the initial entry into the program. Advancement Check this box if the farm is advancing from one level to the next. Monitoring - Check this box if the farm is maintaining its current level.
If the laboratory results and herd management plan has not already been submitt ed, attach the laboratory results and herd management plan with this form.
Publicity Statement: Check "Yes", if the farm is willing for the State to list the farm in any public list of Johne's program herds. Checking "No" or not checking any box will
be counted as the producer does not wish his farm be posted in any public list. Kind of Herd - This space is provided to show on the charts whether the herd is of Dairy,
Beef, or Mixed purpose, plus space is provided to be record the breed of the animals. Signature - Certifying that all information provided is accurate and correct to the best
of your knowledge.

THE VETERINARIAN SHOULD TRANSMIT ALL RECORDS TO THE CENTRAL OFFICE AS SOON AS POSSIBLE.
VS 4-28 (REVERSE)
(JUN 2007)