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valid OMB control number. The valid OMB control number for this information collection is 0579-0146. The time required to complete this information collection is estimated
to average 1.5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
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OMB Approved
0579-0146
EXP: XX/XXXX
COOPERATIVE STATE - FEDERAL TUBERCULOSIS
ERADICATION PROGRAM
UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES
TUBERCULOSIS TEST RECORD
ALL INCOMPLETE RECORDS WILL BE RETURNED FOR COMPLETION
STATE
COUNTY
TWP
SEC
HERD OWNER - LAST NAME, FIRST MI
Serial No.
HERD OWNER COMPLETE ADDRESS
PREVIOUS VET CODE
TEST DATE
TOTAL
REA
CERTIFICATION FOR PAYMENT
HERD NUMBER
SUS
DATE LISTED
STATE/FEDERAL EXPENSE
OWNER EXPENSE
COUNTY
D-B
U
TOWNSHIP OR DISTRICT
1
6
RETEST
HERD
(RE)ACCREDIT
2
3
MILK
ORDINANCE
4
SALE SHOW
5
AFFECTED
HERD
TRACING
REG. KILL
TRACING
REACTORS
TRACING
EXPOSED
OTHER
7
FARM NUMBER
COMPLETE HERD TEST OF ALL
ELIGIBLE ANIMALS
REASON FOR TEST
AREA
SECTION
YES
NUMBER OF ELIGIBLE
ANIMALS IN HERD:
KIND OF HERD
8
NO
DEER
BISON
ELK
CATTLE
CAUDAL FOLD
(CFT)
SNG CERVICAL
(SCT) (CERVID)
CERVICAL
(CT) (BOVINE)
OTHER
AGE
BREED
SEX
NRS
1
SIZE
RESULTS
OFFICIAL
IDENTIFICATION NUMBER
TELEPHONE
NEGATIVE
PRACTITIONER NAME (print)
AGREE CODE
SUSPECT
INJECTION
DATE
HOUR
OBSERVATION
DATE
HOUR
REACTOR
METHOD OF TEST
10
PRACTITIONER SIGNATURE
SUMMARY
OTHER
9
I certify that this test was made and read by me on each of the cattle
identified below on the dates and with the results as entered in
appropriate spaces, and that when payment is claimed at program
expense in accordance with agreement number below, no payment
has been or will be received from any other source.
TOTAL
RESULTS
1
OFFICIAL
IDENTIFICATION NUMBER
1.
16.
2.
17.
3.
18.
4.
19.
5.
20.
6.
21.
7.
22.
8.
23.
9.
24.
10.
25.
11.
26.
12.
27.
13.
28.
14.
29.
15.
TUBERCULIN SERIAL NUMBER
AGE
BREED
30.
I hereby acknowledge receiving a copy of this record which I have
examined and find correct.
RT – Retag
NA – Natural Addition
PA – Purchased Addition
VS Form 6-22
FEB 2020
SEX
NRS
TEST
SIZE
LESION
N – Negative
S – Suspect
R – Reactor
OWNER SIGNATURE
(Previous editions are obsolete.)
DATE
THIS AUTHORIZATION
TO TEST EXPIRES:
| File Type | application/pdf |
| Author | Harris, Sheniqua M - APHIS |
| File Modified | 2023-03-07 |
| File Created | 2019-07-19 |