Aphis 2007 Contact And Qualifications Of Veterinary Biologics Perso

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

CONTACT AND QUALIFICATIONS
OF VETERINARY BIOLOGICS PERSONNEL

(See instructions)

1. EMPLOYEE CONTACT INFORMATION
[A] TITLE

(Dr., Mr., Ms.)

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this information is 0579-0013.
The time required to complete this information collection is estimated to average 0.2 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.

(print information in area requested)

[B] LAST NAME

[D] EST. NUMBER

This report is required by regulations (9 CFR 102.4 and 114.7). Failure to report can result in suspension or revocation of
establishment license.
FORM APPROVED OMB NO. 0579-0013
FORM EXPIRATION DATE: XX/XXXX

FIRST NAME

MIDDLE [C] ESTABLISHMENT NAME
INITIAL

[E] TELEPHONE

[F] ADDRESS OF YOUR PRIMARY WORK SITE

[G] E-MAIL (Recommended)

2. EMPLOYEE ROLE at ESTABLISHMENT

(Use additional lines if necessary)

[A] TITLE of POSITION HELD

[C]

DATE OF PREVIOUS
APHIS FORM 2007
FOR EMPLOYEE
(mm/dd/yy)

[B] FUNCTION(S) or DUTIES

☐

NEW FORM 2007

CHECK THIS BOX IF THERE IS NO
PREVIOUS FORM 2007
FOR EMPLOYEE
AT THIS ESTABLISHMENT

3. EMPLOYEE EDUCATION
[A] NAME of SCHOOL, UNIVERSITY or INSTITUTION

SIGNATURE in BLOCK 5.
CERTIFIES SUBMITTED FORM

[B] TYPE of DEGREE or CERTIFICATION

[C] DATE ATTAINED (mm/yy)

4. SIGNATURE OF EMPLOYEE and DATE SIGNED (mm/dd/yy)

(See Privacy Act Notice at bottom of instructions.)

--------------------------------------------------------------------------------------DATE----------------------------5. [A] CERTIFICATION SIGNATURE (Liaison or Alternate Liaison)
I certify that this person is competent by training, education and experience, and has demonstrated
fitness, in the Functions listed in Block 2., to produce such products in compliance with the Act.

----------------------------------------------------------------------------------------------------------------------------------6. APHIS USE ONLY: Receipt Identification Block

APHIS FORM 2007 (Month 2012)

[B] SIGNATORY TITLE

☐
☐

[C] DATE CERTIFIED
(mm/dd/yy)

LIAISON
ALTERNATE LIAISON

DATE CONTROL AREA

Previous editions are obsolete

INSTRUCTIONS FOR COMPLETING APHIS FORM 2007
An APHIS Form 2007 (Form 2007) must be submitted for each employee who has final responsibility for USDA regulatory issues, research
and product development, product manufacturing, quality control testing, animal acquisition and use, animal disposal and preparation of
APHIS Forms 2008. Please refer to Veterinary Services Memorandum 800.63 for a complete listing of positions requiring Form 2007
and additional instructions. Form 2007 is also used to comply with Veterinary Services Memorandum 800.59 for the role of authorized sampler.
1.

EMPLOYEE CONTACT INFORMATION: Print or Type in each assigned block.
[A, B] Provide information for Official Correspondence.
[C] Provide current name of Licensed Establishment.
[D] Provide assigned USDA Establishment License Number.
[E] Provide telephone country code if primary work site is outside United States.
[F] Provide full physical address, including city and state, of primary work site.
[G] Electronic Mail is strongly encouraged for roles supported by written communications from APHIS such as; Liaison, Alternate
Liaison, Authorized Firm Representative for APHIS Form 2008 releases, and Quality Assurance/Quality Control contact.

2.

EMPLOYEE ROLE at ESTABLISHMENT: Roles of Liaison, Alternate Liaison, and USDA Sampler are confirmed by Official
Correspondence.
[A] List current job title(s) this row.
[B] List employee functions or duties in the production of biologics performed at employee’s primary work.
[C] Provide date of Form 2007 that is to be succeeded at this Establishment, or use Checkbox to indicate a first time submission.

3. EMPLOYEE EDUCATION: Only list education relevant to working in the biologics industry or with biological products
including viruses, serums, toxins, vaccines, allergens, antibodies, antitoxins, toxoids, immunostimulants, diagnostic components or
analogous products. Please list the most recent education first.
[A] Provide the attended NAME of SCHOOL, UNIVERSITY or INSTITUTION accredited to issue degree or certification.
[B] List TYPE of DEGREE or CERTIFICATION program.
[C] Indicate date of issue on the Degree or Certificate attained. If not attained, declare most current YEAR attended, and
total number of years successfully completed (e.g. 2007, 3 years).
4.

SIGNATURE OF EMPLOYEE and DATE SIGNED: Employee signature confirms accuracy of provided information. The date
signed by the employee will be used as the APHIS FORM 2007 process date.

5.

CERTIFICATION SIGNATURE: Liaison or Alternate Liaison signature required to certify competency of employee as stated.

6. APHIS USE ONLY: Do not mark in this Section. Reserved for APHIS processing.

PRIVACY ACT NOTICE
The information requested on this form will not be retrieved from our files by using your name or personal identifier and is therefore, in the opinion of this agency,
not subject to provisions of the Privacy Act of 1974. However, in keeping with the spirit and intent of the Privacy Act we are informing you of the following:
Authority:

9 CFR Section 114.7.

Purpose:

That compliance with the Act and applicable regulations be under supervision of person(s) competent in the preparation of biological
products.

Routine uses:

To determine that the responsible person(s) producing biological products are qualified by training and experience and have demonstrated
fitness to produce such products in compliance with the Act.