VS Form 4-33: Brucellosis Test Record 



STATE, COUNTY 



Enter the location of the herd; it may not be the same 

 as the owner's residence. 



CODE 



Enter the correct county code. A Hst of the Federal In- 

 formation Processing Standards county codes for your 

 State may be obtained from your nearest Veterinary 

 Services area office. If you do not know the correct 

 code, leave the block blank. 



HERD OWNER 



Enter last name, first name, middle initial, and 

 complete mailing address. Be consistent among tests — 

 for example, James Jones v. J. Jones v. Jones Bros. 



LOCATION CODES 



Enter the location codes if appropriate and/or known. 

 Check with the Veterinary Services area office for 

 specific information. 



REASON FOR TEST 



Indicate whether this is the initial test or a retest. If 

 you check the retest block, enter that test date in the 

 PREVIOUS TEST DATE block. The vet code is assigned 

 by your State. This information may be preprinted on 

 the form. Indicate the reason for the test (e.g., export). 

 If none of the first 9 reasons apply, check item 10, 

 Other, and briefly explain in the REMARKS block. 



COMPLETE HERD TEST OF ALL ELIGIBLE ANIMALS 



Check either Yes or No to indicate whether this test is a 

 complete herd test (all eligible animals are being tested). 

 Enter the number of eligible animals in the herd. 



KIND OF HERD 



Enter the type of herd-dairy, beef, or mixed, or swine, 

 or other (e.g., caprine). 



AGREE. CODE 



Certification for payment may be fee-basis or private, 

 depending on the State. Your agreement code is as- 

 signed by your State. 



SIGNATURE 



Sign the form and pro\ide \c)ur address. Remember, 

 this is a legal docu^tment; be sure to sign it. Provide 

 the complete address, including ZIP Code. (The date 

 should be the date the animal was bled.) 



TUBE NO. 



Follow instructions from the laboratory you use on 

 how to number the tubes. 



SIGNATURE 



This is a legal document; be sure to sign it. 



DATE OF VACCINATION 



Enter the date that the \accination was performed. 



AGREE. CODE 



Enter your agreement code provided bv the State. 



CERTIFICATION OF OWNER OR WITNESS 



Have the owner or a witness sign and date the form. 



CERTIFICATION FOR RE-ESTABLISHING 

 VACCINATION STATUS 



Mark this block if calfliood vaccinates are being 

 retagged; sign and date. Retagging is always done 

 at the owner's expense. 



IDENTIFICATION NUMBER 



Enter the vaccination tag number from the eartag that 

 you are applying. Note any other permanent identifica- 

 tion numbers, if present. 



AGE (MO.) I ist the age in months. 



BREED Ise the breed codes listed in table 3. 



SEX Enter F. 



P/B-GRADE 



Mark this block if the animals are purebred (registered) 

 or grade calves. 



TATTOO List the present tattoo if retagging. 



16-10 



