Fillable Form 15.: APPLICATION FORM Category I animals (includes (USDA)

Fill Online, Printable, Fillable, Blank Form 15.: APPLICATION FORM Category I animals (includes (USDA) Form

Use Fill to complete blank online USDA (CO) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form 15.: APPLICATION FORM Category I animals (includes (USDA)

On average this form takes 18 minutes to complete

The Form 15.: APPLICATION FORM Category I animals (includes (USDA) form is 1 page long and contains:

  • 0 signatures
  • 23 check-boxes
  • 61 other fields

Country of origin: US
File type: PDF

U.S.A. forms for USDA

BROWSE USDA (CO) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
VS Form 1-36A
DEC 2013
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 for this information collection is 0579-0297. The time required to complete this collection of information is estimated to average .5 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
0579-0297
Exp. Date: 2/2016
UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES
NATIONAL VETERINARY ACCREDITATION PROGRAM
APPLICATION FORM
1. Initial Accreditation
State: ______ License Number:___________________
2. Authorization in a new State
State: ______ License Number:___________________
3. Change Accreditation Category (Block 15 or 16)
4. Contact Information Change
5. Accreditation Renewal
6. Post-Revocation Re-Accreditation
7. Name of Veterinarian (Last, First, M, Suffix): Check if your name has changed.
8. Six-Digit National Accreditation Number:
_____ _____ _____ _____ _____ _____
9. Other Names Used (e.g., Maiden Name):
10. Date of Birth:
11. School of Veterinary Medicine:
12. Year Graduated:
13. State where First Orientation Completed:
Yes No
ACCREDITATION CATEGORY SELECTION select only one – Block 15 OR 16
15.
Category I animals (includes canines, felines, amphibians/reptiles,
furbearing animals, laboratory animals (rodents), and non-human primates)
Refer to Explanation of Codes Page
Practice Code(s): 3 4 8 9 (select up to two)
Species Code(s): 1 2 12 16 17 (rodents) 18
(
select up to four; this does not limit the number of Category I species upon which you may
perform accredited duties)
Primary Medical Discipline: _______
Employment Type: _______
16.
Category II animals (includes all animals)
Refer to Explanation of Codes Page
Practice Code(s): _______ _______ (list up to two)
Species Code(s): _____ _____ ______ _____ (lis
t up to four; this does not limit the
number of species upon which you
may perform accredited duties)
Primary Medical Discipline: _______
Employment Type: _______
CONTACT INFORMATION
17. Home Mailing Address:
24. Name of Business:
25. Business Mailing Address:
18. City:
19. State:
20. ZIP Code:
26. City:
27. State:
28. ZIP Code:
21. County of Home Mailing Address:
29. County of Business Mailing Address:
22. Home Phone:
30. Business Phone:
23. Email Address: 31. Business FAX Number:
32. Business Cell Phone Number:
33.
May your business contact information be released to the public by the USDA? Yes No
ACCREDITATION RENEWAL OR CHANGE OF ACCREDITATION CATEGORY – Complete only if block 3 or block 5 are selected.
Enter the module numbers, not names, of the APHIS approved supplemental training modules you have completed.
Category I veterinarians: three modules; Category II veterinarians: six modules.
34.
Module Number
35.
Course Type
36.
Date Module
Completed
By signing in block 37, I certify that the information contained in this form is true and correct to the best of my knowledge. I am able to perform the tasks listed in Title 9 Code of Federal Regulations (CFR)
Part 161.1(g) for the accreditation category designated in Blocks 15 or 16. I have been given a copy of the Standards of Accredited Veterinarian Duties contained in Title 9 CFR Part 161.4, and I agree to
conduct all activities as an accredited veterinarian in accordance with the Standards of Accredited Veterinarian Duties.
37. Signature of Veterinarian: 38. Date:
Signature of the Veterinarian-in-Charge and the State Animal Health Official appearing below denotes endorsement of the applicant for Initial Accreditation and/or Post-Revocation
Re-Accreditation.
39. Signature of State Animal Health Official:
40. Date:
41. Signature of Veterinarian-in-Charge: 42. Date:
Previous edition may be used
Instructions for Completing VS Form 1-36A, National Veterinary Accreditation Program (NVAP) Application.
Block 1. Initial Accreditation: Check this block if you are applying for
initial accreditation. Enter the two-letter State abbreviation and your
complete veterinary license number for this State. Complete blocks 1, 7, 9
(if applicable), 10, 11, 12, 13, 14, 15/16, 17-33, 37, and 38.
Block 2. Authorization in a new State: Check this block if you are
seeking authorization to perform accredited duties in an additional State.
Enter the two-letter State abbreviation and your complete veterinary license
number for this State. Complete blocks 2, 7, 8, 9 (if applicable) 10, 17-33,
37, and 38.
Bloc
k 3. Change Accreditation Category: Check this block if you are
changing your Accreditation Category. Complete blocks, 3, 7, 8, 10, 15/16,
and 34-38.
Block 4. Contact Information Change: Check this block if you are
changing your contact information (e.g., name, address). Complete blocks
4, 7
, 8, 10, 37, 38, and the appropriate CONTACT INFORMATION fields.
Block 5. Accreditation Renewal: Check this block if you are renewing
your accreditation. Complete blocks 5, 7, 8, 10, and 34-38. You may not
apply for renewal prior to 6 months of your renewal date.
Block 6
. Post -Revocation Reaccreditation: Check this block if your
accreditation was revoked and you are applying for reaccreditation.
Complete blocks 6, 7, 8, 10, 15/16, 17-33, 37, and 38.
Bloc
k 7. Name of Veterinarian: Enter your legal last name, first name and
middle initial. (If this is a name change request, enter your new legal name
in this block.) Check the block, if your name has changed and complete
Block 9.
Block 8
. Six-Digit National Accreditation No.: Enter the National
Accreditation Number that you have been assigned.
Block
9. Other Names Used (e.g., Maiden Name): Enter other names
used – for example, maiden name, nickname (this name should not be the
same name as in block 7).
Bloc
k 10. Date of Birth: Enter the two-digit month, two-digit day, and four-
digit year of your birth.
Block 11. School of Veterinary Medicine: Enter the name of the school
of veterinary medicine from which you graduated.
Block 12. Year Graduated: Enter your four-digit year of graduation from a
school of veterinary medicine.
Bloc
k 13. State where Orientation Completed: Enter the two letter
abbreviation of the State where core orientation was completed.
Block 14.
Are you interested in participating in State or Federal
agricultural emergency response efforts? Check “yes” or “no”, if you
would like to be contacted to assist with agricultural emergency response
efforts.
Categor
y Selection
(Refer to Explanation of Codes)
Block 15. Category I: Check this block for authorization to only perform
accredited duties on canines, felines, amphibians/reptiles, furbearing
animals, laboratory animals (rodents), and/or non-human primates.
Block 1
6. Category II: Check this block for authorization to perform
accredited duties on all animals.
Species Code(s): Enter up to four code(s) associated with the species with
which you most often expect to perform accredited duties. These entries do
no
t limit the species on which you may perform accredited duties within
your Accreditation Category.
Practice Code(s): Enter up to two code(s) which most clearly describes the
species upon which you will perform accredited duties.
Prima
ry Medical Discipline: Enter the number associated with the
discipline that best describes your primary medical discipline.
Employment Type: Enter the number associated with your employment
type.
Home Cont
act Information
Block 1
7. Home Mailing Address: Enter your complete home mailing
address. This is the address that will be used by NVAP to communicate
with you.
Block 1
8. City: Enter the city of your home address.
Bloc
k 19. State: Enter the two-letter state abbreviation of your home
address.
Block 2
0. ZIP Code: Enter the five- or nine-digit ZIP code of your home
address.
Block 21.
County of Home Mailing Address: Enter the county in which
your home address is located.
Block 22
. Home Phone: Enter your 10-digit home phone number.
Block 23. Email Address: Enter your email address. (NOTE: If you enter
a shared email address, that information may be viewed by others.)
Busines
s Contact Information
Block 24. Name of Business: Enter the name of the business where you
work/practice. If you are self-employed without a specific business name,
enter your name from Block 7.
Block 25. Business Mailing Address: Enter complete business mailing
address. If your home mailing address is your business mailing address,
write “Same as home address.”
Block 2
6. City: Enter the city of your business address.
Block 2
7. State: Enter the two-letter state abbreviation of your business
address.
Block 2
8. ZIP Code: Enter the five- or nine-digit ZIP code of your business
address.
Block 29. County of Business Mailing Address: Enter the county in
which your business address is located.
Block 30. Bus
iness Phone Number: Enter your 10-digit business phone
number.
Block 31.
Business Cell Number: Enter your 10-digit cell phone number.
Block 32
. Business FAX Number: Enter your 10-digit fax number.
Block 33. May your business contact information be released to the
public by the USDA? Check "yes" or "no" to having your business
contact information released.
Block 34. Module Number: Enter the module numbers, not the names, of
the APHIS approved supplemental training modules you have comple
ted.
Category I veterinarians: three modules; Category II veterinarians: six
modules
Block 35. Course Type: Enter either Online, Lecture, CD, or Print. The
CD and Print designations indicate that you purchased a CD or printed
version of the module from the Center for Food Security and Public Health
at Iowa State University.
Block 36. Date Module Completed: Enter the two-digit month, two-digit
day, and four-digit year that you completed the module.
Certification/Approval
Block 37. Signature of Veterinarian: Read the certification statement
above block 37 and si
gn in blue or black ink. (NOTE: The applicant MUST
be licensed or legally able to practice as a veterinarian.)
Block 38. Date: Enter the two-digit month, two-digit day, and four-digit
year that you signed this application.
Blocks 39-42: Do not enter any information in these blocks.
VS Form 1-36A
DEC 2013
P
RIVACY ACT NOTICE
General:
T
his information is provided pursuant to Public Law 95-3579 (Privacy Act of 1974) December 31, 1974, for individuals completing the VS 1-36A.
Authority:
5 U
.S.C. 3301, 7 U.S.C. 8309, and 21 U.S.C. 113a
Routine Uses:
T
he information will be used for (1) Referral to State Animal Health officials to certify accreditation status or to exchange information regarding disciplinary action(s). (2)
Referral to state veterinary examining boards to certify accreditation status or to exchange information regarding disciplinary action(s). (3) Disclosure to the public for the
purpose of locating and contacting accredited veterinarians for a specific geographical location. (4) Referral to the appropriate agency, whether Federal, State, local or
foreign, charged with the responsibility of investigating or prosecuting a violation of law, or of enforcing or implementing a statute, rule, regulation or order issued pursuant
there to, of any record within this system when information available indicates a violation or potential violation of law, whether civil, criminal or regulatory in nature, and
whatever arising by general statue or particular program statue, or by rule, regulation or order issued pursuant thereto. (5) Disclosure to the Department of Justice has
agreed to represent the employee or the United States, where the agency determined that litigation is likely to affect the agency or any of its components, is a party to litigation
or has an interest in such litigation and the use of such records by the Department of Justice is deemed by the agency to be relevant and necessary to the litigation ; provided,
however, that in each case the agency determines that disclosure of the records to be Department of Justice is a use of the information contained in the records that is
compatible with the purpose for which the records were collected. (6) Disclosure in a proceeding before a court of adjudicative body before which the agency is authorized to
appear, when the agency, or any component thereof, or any employee of the agency in his or her official capacity, or any employee of the agency in his or her individual
capacity where the agency has agreed to represent the employee or the United States, where the agency determines that litigation is likely to affect the agency or any of its
components, is a party to litigation or has an interest in such litigation, and the agency determines that use of such records is relevant and necessary to the litigation; provided,
however, that in each case the agency determines that disclosure of the records to the court is a use of the information contained in the records that is compatible with the
purpose for which the records were collected (7) Disclosure to appropriate agencies, entities, and persons when the agency suspects or has confirmed that the security or
confidentiality of information in the system of records has been compromised; the agency has determined that as a result of the suspected or confirmed compromise there is a
risk of harm to economic or property interests, a risk of identity theft or fraud, or a risk of harm to the security or integrity of this system or other systems or programs (whether
maintained by the agency or another agency or entity) that rely upon the compromised information; and the disclosure made to such agencies, entities, and persons is
reasonably necessary to assist in connection with the agency’s efforts to respond to the suspected or confirmed compromise and prevent, minimize, or remedy such harm; (8)
Disclosure to cooperative Federal, State, and local government officials, employees, or contractors, and other parties engaged to assist in administering the program. Such
contractors and other parties will be bound by the nondisclosure provisions of the Privacy Act. This routine use assists the agency in carrying out the program, and thus is
compatible with the purpose for which the records are created and maintained. (9) Disclosure to USDA contractors, partner agency employees or contractors, or private
industry employed to identify patterns, trends or anomalies indicative of fraud, waste, or abuse. (10) Disclosure to the National Archives and Records Administration or to the
General Services Administration for records management inspections conducted under 44 U.S.C. 2904 and 2906.
Effects of Nondisclosure:
A
lthough this information is voluntary, failure to complete all the information may delay the process of the application or it may result in the application not being processed.
VS Form 1-36A
DEC 2013
Explanation of Codes
Practice Codes (Blocks 15 & 16)
(May indicate up to 2 codes)
(“Predominant” = Greater than 50%
Species Contact,
“Exclusive” = Only Species Contact)
1 - Food Animal Predominant
2 - Food Animal Exclusive
3 - Companion Animal Predominant
4 - Companion Animal Exclusive
5 - Mixed Animal
6 - Equine Predominant
7 - Equine Exclusive
8 - Other
9 - No Species Contact
Species Codes (Blocks 15 & 16)
(May choose up to 4 codes)
1 - Canine
2 - Feline
3 - Equine
4 - Bovine
5 - Porcine
6 - Ovine/Caprine
7 - Camelid
8 - Cervid
9 - Poultry
10 - Avian (non-poultry)
11 - Exotics
12 - Amphibian/Reptile
13 - Aquatic Animal
14 - Zoo Animal
15 - Wildlife
16 - Furbearing Animals
17 - Laboratory Animal
18 - Non-Human Primate
19 - Other Species
20 - No Species Contact
Primary Medical Disciplines
(Blocks 15 & 16)
(Choose only 1 discipline)
1 - Anatomy
2 - Anesthesiology
3 - Animal Behavior
4 - Animal Welfare
5 - Alternative/Contemporary
6 - Association Management
7 - Biochemistry
8 - Biomedical Engineering
9 - Business/Economics
10 - Cardiology
11 - Dentistry
12 - Dermatology
13 - Disaster Medicine
14 - Ecology
15 - Emergency and Critical Care
16 - Endocrinology
17 - Environmental Health
18 - Epidemiology
19 - Ethics
20 - General Medicine
21 - Genetics
22 - Human Animals Bond
23 - Homeland Security
24 - Immunology
25 - Internal Medicine
26 - Insurance
27 - Laboratory Animal Medicine
28 - Law
29 - Media
30 - Microbiology
31 - Mycology/Bacteriology
32 - Molecular Biology
33 - Neurology
34 - Non-Medical
35 - Nutrition
36 - Oncology
37 - Ophthalmology
38 - Parasitology
39 - Pathology - Anatomic
40 - Pathology – Clinical
41 - Pharmacology
42 - Pharmacology – Clinical
43 - Physiology
44 - Population Medicine
45 - Poultry Medicine
46 - Preventative Medicine
47 - Production Medicine
48 - Public Health
49 - Radiology
50 - Shelter Medicine
51 - Sports Medicine
52 - Surgery
53 - Theriogenology
54 - Toxicology
55 - Virology
56 - W
ildlife Medicine
57 - Zoological Medicine
58 - Other Professional Discipline
Employment Type (Blocks 15 & 16)
(May choose only 1 type)
Private Clinical Practice
1 - General Medicine/Surgery
2 - Production Medicine
3 - Referral/Specialty Medicine
4 - Emergency/Critical Care Medicine
5 - Other Private Clinical Practice
A
cademia
6 - Veterinary Medical College/School
7 - Veterinary Science Department
8 - Veterinary Technician Program
9 - Animal Science Department
10 - Other Academia
Government
11 - U.S. Federal
12 - State
13 - Local
14 - Foreign
15 - Army
16 - Air Force
17 - Public Health Commission Corps
18 - Other Government
Industry/Commercial
19 - Pharmaceutical/Biological
20 - Feeds/Nutrition
21 - Laboratory
22 - Agriculture/Livestock Production
23 - Business/Consulting Services
24 - Other Industry/Commercial
O
ther
25 - Humane Organization
26 - Membership Assn/Professional
Society
27 - Foundation/Charitable Organization
28 - Missionary/Service
29 - Zoo/Aquarium
30 - Wildlife
32 - Temp Not Employment in Veterinary
Field
33 - Non-Veterinary Employment
34 - Not Employed
35 - Not Listed Above
This Professional Classification System is used courtesy of the American Veterinary Medical Association.
VS Form 1-36A
DEC 2013
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form 15.: APPLICATION FORM Category I animals (includes (USDA)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 29 July 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document