VS 9-20 Application for U.S. Avian Influenza and Newcastle Disea

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 numbers for this information collection are 0579-0007 and 0579-XXXX. 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 and XXXX

Application For U.S. Avian Influenza
and Newcastle Disease
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. ND 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 and Newcastle 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
APR 2019

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 and Newcastle 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
ND Vaccination Program
ND Testing Program for ND vaccinated or unvaccinated flocks

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 and
Newcastle Disease Clean Compartment program a participant in good standing with
the NPIP: U.S. H5/H7 Avian Influenza Clean and Newcastle Disease Clean Programs
for Turkey Breeding Flocks?
Is the company seeking certification in the U.S. Avian Influenza and Newcastle
Disease Clean Compartment program a participant in good standing with the NPIP:
U.S. Avian Influenza Clean and Newcastle Disease Clean Programs for Primary EggType Chicken Breeding Flocks?
Is the company seeking certification in the U.S. Avian Influenza and Newcastle
Disease Clean Compartment program a participant in good standing with the NPIP:
U.S. Avian Influenza Clean and Newcastle Disease Clean Programs for Primary MeatType Chicken Breeding Flocks?
Within the company, are all operations seeking certification as components within
the registered compartment in the U.S. Avian Influenza and Newcastle Disease
Clean Compartment program (for egg- type chicken breeding flocks and meat-type
chicken breeding flocks) or the U.S,. H5/H7 Avian Influenza and Newcastle Disease
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 and Newcastle
Disease Clean Compartment program perform routine surveillance of all flocks
within the compartment in an NPIP-authorized laboratory which is certified to test
for AI and ND?

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.Heard@aphis.usda.gov
with cc to
Christina.Lindsey@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.