VS Form 9-21 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 0579-0474. 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 0474

Application For U.S. Avian Influenza
and Newcastle Disease
Clean Compartment Component Registration
Instructions: Step 1: Applicants, please complete Sections A-E and certify application with signature on pg. 6. Step
2: Send the form to the OSA which completes Section F and signs. Step 3: OSA returns form to NPIP. Note: If you are
using Form B to comply with recertification requirements and none of the information in Sections A-E has changed
since initially applying, please complete only Section A and proceed to Step 2. Disclaimer: For initial Compartment
and Component registration, this form may be simultaneously submitted with Application Form A: Compartment
Registration for initial 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.
To be considered for approval as a new component within a certified compartment, the following must
be completed.

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
Total Number of Components Seeking
Certification (sum of total numbers
listed in sections B-E below)

VS FORM 9-21
APR 2019

Farm  Feedmill  Hatchery  Egg Depot 

Questionnaire. To be completed by company seeking certification.
Please place a check mark by the answer that applies.
U.S. Avian Influenza and Newcastle Disease Compartment Registration Form
(Application Form A) submitted. This form contains the components to be added
within the new compartment.
New facility within previously certified compartment.
Requalification of components within certified compartment due.
Components previously removed from certified compartment and now seeking
reinstatement within certified compartment.

YES

NO

B. Prerequisites for Farms (F). To be completed by company seeking certification.
To be considered for approval as a component in a certified compartment, you must first provide the
following information.
Total number of farm premises seeking approval (Please list number).
List farm names (and associated NPIP numbers) seeking approval in box provided below. Separate farms
by use of a semicolon. Example: ChickaD, 13-3223: Hollow Oak 1, 12-1392; Hollow Oak 2, 12-1293. This
example includes three separate farms and three separate NPIP numbers or EMRS Premises
Identification Numbers.

Note: Supporting documents for Statements 1 and 2 below must be submitted with this application for
each farm. Please 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 verification of
statement 3.
Farm Design, Physical Requirements, and Management Protocols
Statement 1: FMP 1: Site plan for each farm in the component which shows
characteristics of the component.
I hereby certify that I have attached to this application a site plan for each farm
seeking to be added as a component within the compartment.
Statement 2: FMP 2: Farm specifications, including fencing, signage, and
construction. (Note that farm specifications include the physical address of each
farm along with GPS coordinates.)

YES

NO

I hereby certify that I have attached to this application the applicable farm
specifications for each farm seeking to be added as a component within the
compartment.
Statement 3: FMP3-FMP13: Written documentation must be shown to the assigned
auditor on request.
I hereby certify that written documentation for each of the Farm Management
Protocols 3-13 is on file as accurate and complete to my knowledge and will be
provided to the assigned auditor on request.

YES

NO

C. Prerequisites for Feedmills (M). To be completed by the company seeking certification.
To be considered for approval as a component in a certified compartment, you must first provide the
following information.
Total number of feedmill premises seeking approval (Please list number).
List feedmill names seeking approval in box provided below. Separate feedmills by use of a semicolon.
Example: Feedmille 1; Jones & Parks; Willow Mill. This example includes three separate feedmills.

Note: Supporting documents for Statements 1 and 2 below must be submitted with this application for
each feedmill. Please 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 verification of
statement 3.
Feedmill Design, Physical Requirements, and Management Protocols
Statement 1: FMMP 1: Site plan for each feedmill in the component which
shows characteristics of the component.
I hereby certify that I have attached to this application a site plan for each
feedmill seeking to be added as a component within the compartment.
Statement 2: FMMP 2: Feedmill specifications, including signage and construction.
(Note that feedmill specifications include the physical address of each feedmill along
with GPS coordinates.)
I hereby certify that I have attached to this application the applicable
feedmill specifications for each feedmill seeking to be added as a component
within the compartment.

YES

NO

Statement 3: FMMP3-FMMP9: Written documentation must be shown to the
assigned auditor on request.
I hereby certify that written documentation for each of the Feedmill Management
Protocols 3-9 is on file as accurate and complete to my knowledge and will be
provided to the assigned auditor on request.

YES

NO

D. Prerequisites for Hatcheries (H). To be completed by company seeking certification.
To be considered for approval as a component in a certified compartment, you must first provide the
following information.
Total number of hatchery premises seeking approval (Please list number).
List hatchery names (and associated NPIP numbers) seeking approval in box provided below. Separate
hatcheries by use of a semicolon. Example: Chickadee, Inc. -15-1425; Grandparent Line-65-1293. This
example includes two separate hatcheries with two separate NPIP numbers.

Note: Supporting documents for Statements 1 and 2 below must be submitted with this application for
each hatchery. Please 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 verification of
statement 3.
Hatchery Design, Physical Requirements, and Management Protocols
Statement 1: HMP 1: Site plan for each hatchery in the component which
shows characteristics of the component.
I hereby certify that I have attached to this application a site plan for each
hatchery seeking to be added as a component within the compartment.
Statement 2: HMP 2: Hatchery specifications, including fencing, signage, and
construction. (Note that hatchery specifications include the physical address of each
hatchery along with GPS coordinates.)
I hereby certify that I have attached to this application the applicable hatchery
specifications for each hatchery seeking to be added as a component within
the compartment.
Statement 3: HMP3-HMP15: Written documentation must be shown to the assigned
auditor on request.
I hereby certify that written documentation for each of the Hatchery
Management Protocols 3-15 is on file as accurate and complete to my knowledge
and will be provided to the assigned auditor on request.

YES

NO

E. Prerequisites for Egg Depots (E). To be completed by company seeking certification.
To be considered for approval as a component in a certified compartment, you must first provide the
following information.
Total number of egg depot premises seeking approval (Please list number).
List egg depot names seeking approval in box provided below. Separate egg depots by use of a
semicolon. Example: Clayton 1, 2, and 3; Heart Storage. This example includes two separate egg depots.
Alternatively, Egg Depot location may be identified with NPIP number +/- EMRS premises identification
number.

Note: Supporting documents for Statements 1 and 2 below must be submitted with this application for
each egg depot. Please 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 verification of
statement 3.
Egg Depot Design, Physical Requirements, and Management Protocols
Statement 1: EDMP 1: Site plan for each hatchery in the component which
shows characteristics of the component.
I hereby certify that I have attached to this application a site plan for each egg
depot seeking to be added as a component within the compartment.
Statement 2: EDMP 2: Hatchery specifications, including fencing, signage, and
construction. (Note that egg depot specifications include the physical address of
each egg depot along with GPS coordinates.)
I hereby certify that I have attached to this application the applicable egg depot
specifications for each hatchery seeking to be added as a component within the
compartment.
Statement 3: EDMP3-EDMP12: Written documentation must be shown to the
assigned auditor on request.
I hereby certify that written documentation for each of the Egg Depot
Management Protocols 3-12 is on file as accurate and complete to my knowledge
and will be provided to the assigned auditor on request.

YES

NO

YES

NO

F. Verification. 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/H7Avian 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
Meat-Type Chicken Breeding Flocks?
Within the company, are all operations seeking certification as components within
the registered compartment participating 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 program (for turkey breeding flocks)
located in a State which has an APHIS-approved Initial State Response and
Containment Plan?

YES

NO

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:
For Components Denied, if Any, List Reasons:

Please note that registration approval for components does not mean the components are certified. Only
after an auditor’s review and successful passing can a component become certified.