VS Form 9-20 Application For U.S. Avian Influenza Clean Compartment R

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 of this information collection is 0579-0007. The time required to complete this information collection is estimated to
average 40 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.

OMB Approved
0579-0007
EXP: XX/XXXX

Application For U.S. Avian Influenza
Clean Compartment Registration
Instructions: Step 1: Applicants, please complete Sections A and B and certify application with signature
on pg. 3. Step 2: Send Form A to the OSA which completes Section C and signs. Step 3: OSA returns form to NPIP.
Note: If you are using Form A to comply with recertification requirements and none of the information in Sections A
or B has changed since initially applying, please complete only Section A and proceed to Step 2. Disclaimer: This
form may be simultaneously submitted with Application Form B: Component Registration. However, Application
Form B will not be reviewed until Application Form A has been reviewed and approved.

A: Background Information. To be completed by company seeking certification.
Name of Company
Company Mailing Address
Name of Contact
Telephone Number
Alternate Telephone Number
Fax Number
Email Address
NPIP Classification

U.S. AI Clean 

U.S. H5/H7 AI Clean 

Breed/Type of Poultry
NPIP Classification Seeking
Compartment Mailing Address
Compartment Location (List States
Involved)
Name of Compartment
Anticipated Type of Components (F, M,
H, and E) to add within Compartment

Farm  Feedmill  Hatchery  Egg Depot 

B: Prerequisites. To be completed by company seeking certification.
To be eligible for certification as a compartment, all of the protocols listed below and supporting
documents must be available and ready for presentation to the compartmentalization auditors. Refer to
the Compartmentalization for Protection Against Avian Influenza Disease in Primary Poultry Breeding
Companies in the United States of America; Specifications for Management Procedures, Physical
Requirements and Protocols for more details.

VS FORM 9-20
OCT 2018

Please place a check mark by the answer that applies.
General Management Protocols
For each component, have you met all of the required specifications for
management procedures and physical requirements; do you have the necessary
protocols and documentation as specified in the Compartmentalization for
Protection Against Avian Influenza Disease in Primary Poultry Breeding
Companies in the U.S.A. and further, do you have documentation outlining the
following items?

Yes

No

Yes

No

Biosecurity training for employees, contract staff, and visitors
Biosecurity compliance agreement for employees, contract staff, and visitors
Biosecurity risk assessment for each component of the compartment
Cleaning, sanitation, and control of vehicles prior to entering biosecure areas
General physical traits of each compartment component
(Farms, Feedmills, Hatcheries, Egg Depots and Offices), including physical address
with GPS location
Detailed diagrammatic description for movement of people, vehicles, equipment,
birds, and eggs between all components inside and outside the compartment
Company Emergency Response Plan
Veterinary Health Plan

C. Questionnaire. To be completed by each Official State Agency
Please place a check mark by the answer that applies.
Is the company seeking certification in the U.S. H5/H7 Avian Influenza Clean
Compartment program a participant in good standing with the NPIP: U.S. H5/H7
Avian Influenza Clean Program for Turkey Breeding Flocks?
Is the company seeking certification in the U.S. Avian Influenza Clean Compartment
program a participant in good standing with the NPIP: U.S. Avian Influenza Clean
Program for Primary Egg-Type Chicken Breeding?
Is the company seeking certification in the U.S. Avian Influenza Clean Compartment
program a participant in good standing with the NPIP: U.S. Avian Influenza Clean
Program for Primary Meat-Type Chicken Breeding Flocks?
Within the company, are all operations seeking certification as components within
the registered compartment in the U.S. Avian Influenza Clean Compartment
program (for egg- type chicken breeding flocks and meat-type chicken breeding
flocks) or the U.S, H5/H7 Avian Influenza Clean Compartment (for turkey breeding
flocks) located in a State which has an APHIS-approved Initial State Response and
Containment Plan?
Does the company seeking certification in the U.S. Avian Influenza Clean
Compartment program perform routine surveillance of all flocks within the
compartment in an NPIP- authorized laboratory which is certified to test for AI?

CERTIFICATION OF OFFICIAL STATE AGENCY or AGENCIES
I DO HEREBY CERTIFY THAT ALL STATEMENTS MADE BY ME IN THIS APPLICATION ARE TRUE AND
CORRECT TO THE BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF; FURTHER, I UNDERSTAND THAT
IN THE EVENT I HAVE KNOWINGLY AND WILLFULLY MADE ANY FALSE STATEMENTS, I WILL BE LIABLE
FOR PUNISHMENT IN ACCORDANCE WITH ALL APPLICABLE LAWS AND STATUTES.
State:

State:

Signature:

Signature:

Date:

Date:

State:

State:

Signature:

Signature:

Date:

Date:

CERTIFICATION OF APPLICANT
I DO HEREBY CERTIFY THAT ALL STATEMENTS MADE BY ME IN THIS APPLICATION ARE TRUE AND
CORRECT TO THE BEST OF MY KNOWLEDGE, INFORMATION, AND BELIEF AND I HAVE OBTAINED ALL
NECESSARY OFFICIAL STATE AGENCIES' CERTIFICATION IN C ABOVE. FURTHER, I UNDERSTAND THAT IN
THE EVENT I HAVE KNOWINGLY AND WILLFULLY MADE ANY FALSE STATEMENTS, I WILL BE LIABLE FOR
PUNISHMENT IN ACCORDANCE WITH ALL APPLICABLE LAWS AND STATUTES.
Signature:
Date:

Application
A complete application must be sent to:
The National Poultry
Improvement Plan
1506 Klondike Road,
Suite 101
USDA-APHIS-VS
Conyers, GA 30094
Denise.L.Brinson@aphis.usda.gov
with cc to
Elena.L.Behnke@aphis.usda.gov

For Department Use Only
Date
Received:

Reviewer:

Check Here if Registration Approval Granted: 
Check Here if Registration Approval Denied:



Signature:
If Denied, List Reasons:

Please note that registration approval does not mean that the component is certified. Only after a
successful registration using this form, a successful registration of components using Application Form B,
and a successful audit can the compartment become fully certified.