Form VS 11-2 VS 11-2 Application for Chronic Wasting Disease Herd Certifcatio

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to
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respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0579-0189. The time required to complete this information collection is estimated to average between
0579-0189
EXP.: XX/XXXX
10 and 20 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.
UNITED STATES DEPARTMENT OF AGRICULTURE
APPLICATION FOR CHRONIC WASTING DISEASE HERD
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
CERTIFICATION PROGRAM (CWD HCP) APPROVAL, RENEWAL, OR
VETERINARY SERVICES
REINSTATEMENT OF A STATE
1. STATE
2. APPLICATION FOR (“X” one)
APPROVED STATUS
RENEWAL OF APPROVED STATUS
REINSTATEMENT OF APPROVED STATUS
3. REPORTING PERIOD:
4. STATUS OF ACTION ITEMS IDENTIFIED ON THE LAST RENEWAL OR AS PART OF AN APPROVED STATE REVIEW
(Use an attachment sheet, if necessary)

5. QUALIFICATION (“X” all that apply)
A.

The requirements of 9 CFR 55.23 (a) have been met. State CWD HCP regulations, program policies and standards, legal authorities, and other

supporting documentation are attached. (The supporting documentation must describe which requirement(s) of 9 CFR 55.23 are being met.)
B.

The CWD National Database OR an equivalent State database to maintain CWD HCP data is updated as needed and data are current, accurate

and complete for the reporting period.
C.

The annual Approved State CWD HCP Report has been completed and submitted to the VS Regional Office.
6. INVENTORY OF ENROLLED HERDS

A. TOTAL NO. OF ENROLLED
DEER HERDS

B. TOTAL NO. OF ENROLLED
ELK HERDS

C. TOTAL NO. OF DEER
ENROLLED IN HCP

D. TOTAL NO. OF ELK ENROLLED
IN HCP

Comments (Note any mixed herds, etc):

7. SURVEILLANCE ACTIVITIES
A.

Number of animals tested through
on-farm surveillance

B. Number of animals tested at slaughter

C. Number of animals tested at hunt facilities
(shooter operations)

CERTIFICATION
The provisions of 9 CFR Parts 55 and 81 have been met. APHIS requests that this State be designated an Approved State CWD HCP.
8. Signature of State Official
9. Please Type or Print Name
10. Date
11. Signature of Area Veterinarian in Charge

12. Please Type or Print Name

13. Date

14. Approval by VS Region
Application for Approved Status is complete and approved
approved.

Renewal of Approved Status is approved

Reinstatement of Approved Status is

Form is being returned for completion or correction
Renewal or Reinstatement of Approved Status is provisionally approved contingent on the conditions listed in the attachment being met by the
following date: ________________
15. Signature of Regional Epidemiologist

16. Please Type or Print Name

17. Date

18. Veterinary Services hereby declares the above State Approved for the period beginning _______________ and ending ________________
19. Signature of CWD Program Certifying Official
20. Please Type or Print Name
21. Date

VS FORM 11-2
APR 2012