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FORM APPROVED: Submit completed form only once by (Department of Health and Human Services)

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REPORTING THE IDENTIFICATION OF A SELECT AGENT OR
TOXIN: FEDERAL LAW ENFORCEMENT SEIZURE REPORT
(APHIS/CDC FORM 4C)
FORM APPROVED
OMB NO. 0579-0213
OMB NO. 0920-0576
EXP DATE 10/31/2020
INSTRUCTIONS
Detailed instructions are available at http://www.selectagents.gov/form4.html. Answer all items completely and type or print in
ink. This report must be signed and submitted to either APHIS or CDC:
Animal and Plant Health Inspection Service
Agriculture Select Agent Program
4700 River Road Unit 2, Mailstop 22, Cubicle 1A07
Riverdale, MD 20737
FAX: (301) 734-3652
E-mail: AgSAS@aphis.usda.gov
Centers for Disease Control a nd Prevention
Division of Select Agents and Toxins
1600
Clifton
Road
NE,
Mailstop
A-46
Atlanta, GA
30329
FAX:
(404)
471-8469
E-mail:
CDCForm4@cdc.gov
Accession Number:
(For Program Use ONLY)
Submit completed form only once by either e-mail, fax, or mail
SECTION A – FEDERAL LAW ENFORCEMENT INFORMATION
1. Name of federal law enforcement agency:
2. Name of federal law enforcement agent:
First: MI: Last:
3. Telephone #:
4. Fax #:
5.
E-mail address:
SECTION B – SELECT AGENTS AND TOXINS SEIZED
1. Name of entity select agent or toxin seized from:
2. Select agent or toxin seized
3. Amount seized
4. Disposition of seized select agent or toxin
5. Were any of the seized select agents or toxins handled outside of primary containment which may have led to an unintentional release and/or exposure to the select
agent or toxin?
No Yes (If Yes, you are required under 7 CFR §331.19, 9 CFR §121.19, and 42 CFR §73.19 to complete and submit an APHIS/CDC Form 3)
6. Comments / Notes:
I hereby certify that the information contained on this form is true and correct to the best of my knowledge. I understand that if I knowingly provide a false statement on any part of this form,
or its attachments, I may be subject to criminal fines and/or imprisonment. I further understand that violations of 7 CFR Part 331, 9 CFR Part 121, or 42 CFR Part 73 may result in civil or
criminal penalties, including imprisonment.
Signature of Agent: ___________________________________________________ Date Signed: _______________________________
Public reporting burden: Public reporting burden of providing this information is estimated to average 1 hour 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. An agency may not conduct or sponsor, and a person is not required
to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D74, Atlanta, Georgia 30329 ATTN: PRA (0920-0576).
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FORM APPROVED: Submit completed form only once by (Department of Health and Human Services)

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Completed 25 January 2021

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