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

Clear Form
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 0579-0189. The time
required to complete this information collection is estimated to average 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
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES
1. STATE

OMB APPROVED
0579-0189
EXP.: XX/XXXX

APPLICATION FOR CHRONIC WASTING DISEASE HERD
CERTIFICATION PROGRAM (CWD HCP) APPROVAL, RENEWAL, OR
REINSTATEMENT OF A 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 NUMBER OF ENROLLED
DEER HERDS

B. TOTAL NUMBER OF
ENROLLED ELK HERDS

C. TOTAL NUMBER OF DEER
ENROLLED IN HCP

D. TOTAL NUMBER OF ELK
ENROLLED IN HCP

Comments (Note any mixed herds, etc.):

A. NUMBER OF ANIMALS TESTED
THROUGH ON-FARM SURVEILLANCE

7. SURVEILLANCE ACTIVITIES
B. NUMBER OF ANIMALS TESTED AT
SLAUGHTER

C. NUMBER OF ANIMALS TESTED AT HUNT
FACILITIES (SHOOTER OPERATIONS)

CERTIFICATION
Application and related documents have been submitted for review. Results of the completed review are indicated in block 14 below.
8. Signature of State Official
9. Type or Print Name
10. Date

11. Signature of Area Veterinarian in Charge

12. Type or Print Name

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

13. Date

Provisional Approved Status is approved.

Reinstatement of Approved Status is approved.

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. 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. Type or Print Name
21. Date

VS FORM 11-2
AUG 2012