VS Form 1-36a "National Veterinary Accreditation Program Application Form"

What Is VS Form 1-36a?

This is a legal form that was released by the U.S. Department of Agriculture - APHIS Veterinary Services on December 1, 2013 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2013;
  • The latest available edition released by the U.S. Department of Agriculture - APHIS Veterinary Services;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of VS Form 1-36a by clicking the link below or browse more documents and templates provided by the U.S. Department of Agriculture - Aphis Veterinary Services.

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Download VS Form 1-36a "National Veterinary Accreditation Program Application Form"

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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
OMB Approved
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
0579-0297
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.
Exp. Date: 2/2016
1. Initial Accreditation
2. Authorization in a new State
UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
State: ______
License Number:___________________
State: ______ License Number:___________________
VETERINARY SERVICES
3. Change Accreditation Category (Block 15 or 16)
4. Contact Information Change
NATIONAL VETERINARY ACCREDITATION PROGRAM
.
APPLICATION FORM
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:
14. Are you interested in participating in State or Federal agricultural emergency response efforts?
13. State where First Orientation Completed:
Yes
No
ACCREDITATION CATEGORY SELECTION select only one – Block 15 OR 16
15.
16.
(includes canines, felines, amphibians/reptiles,
(includes all animals)
Category I animals
Category II animals
furbearing animals, laboratory animals (rodents), and non-human primates)
Refer to Explanation of Codes Page
Refer to Explanation of Codes Page
Practice Code(s):
3
4
8
9
(select up to two)
Practice Code(s):
_______
_______
(list up to two)
Species Code(s):
1
2
12
16
17 (rodents)
18
Species Code(s):
_____
_____
______
_____
(list up to four; this does not limit the
(select up to four; this does not limit the number of Category I species upon which you may
number of species upon which you
perform accredited duties)
may perform accredited duties)
Primary Medical Discipline:
_______
Primary Medical Discipline:
_______
Employment Type:
_______
Employment Type:
_______
CONTACT INFORMATION
24. Name of Business:
17. Home Mailing Address:
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
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
OMB Approved
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
0579-0297
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.
Exp. Date: 2/2016
1. Initial Accreditation
2. Authorization in a new State
UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
State: ______
License Number:___________________
State: ______ License Number:___________________
VETERINARY SERVICES
3. Change Accreditation Category (Block 15 or 16)
4. Contact Information Change
NATIONAL VETERINARY ACCREDITATION PROGRAM
.
APPLICATION FORM
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:
14. Are you interested in participating in State or Federal agricultural emergency response efforts?
13. State where First Orientation Completed:
Yes
No
ACCREDITATION CATEGORY SELECTION select only one – Block 15 OR 16
15.
16.
(includes canines, felines, amphibians/reptiles,
(includes all animals)
Category I animals
Category II animals
furbearing animals, laboratory animals (rodents), and non-human primates)
Refer to Explanation of Codes Page
Refer to Explanation of Codes Page
Practice Code(s):
3
4
8
9
(select up to two)
Practice Code(s):
_______
_______
(list up to two)
Species Code(s):
1
2
12
16
17 (rodents)
18
Species Code(s):
_____
_____
______
_____
(list up to four; this does not limit the
(select up to four; this does not limit the number of Category I species upon which you may
number of species upon which you
perform accredited duties)
may perform accredited duties)
Primary Medical Discipline:
_______
Primary Medical Discipline:
_______
Employment Type:
_______
Employment Type:
_______
CONTACT INFORMATION
24. Name of Business:
17. Home Mailing Address:
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
VS Form 1-36A
DEC 2013
Instructions for Completing VS Form 1-36A, National Veterinary Accreditation Program (NVAP) Application
.
Home Contact Information
Block 1. Initial Accreditation: Check this block if you are applying for
initial accreditation. Enter the two-letter State abbreviation and your
Block 17. Home Mailing Address: Enter your complete home mailing
complete veterinary license number for this State. Complete blocks 1, 7, 9
address. This is the address that will be used by NVAP to communicate
(if applicable), 10, 11, 12, 13, 14, 15/16, 17-33, 37, and 38.
with you.
Block 2. Authorization in a new State: Check this block if you are
Block 18. City: Enter the city of your home address.
seeking authorization to perform accredited duties in an additional State.
Enter the two-letter State abbreviation and your complete veterinary license
Block 19. State: Enter the two-letter state abbreviation of your home
number for this State. Complete blocks 2, 7, 8, 9 (if applicable) 10, 17-33,
address.
37, and 38.
Block 20. ZIP Code: Enter the five- or nine-digit ZIP code of your home
Block 3. Change Accreditation Category: Check this block if you are
address.
changing your Accreditation Category. Complete blocks, 3, 7, 8, 10, 15/16,
and 34-38.
Block 21. County of Home Mailing Address: Enter the county in which
Block 4. Contact Information Change: Check this block if you are
your home address is located.
changing your contact information (e.g., name, address). Complete blocks
4, 7, 8, 10, 37, 38, and the appropriate CONTACT INFORMATION fields.
Block 22. Home Phone: Enter your 10-digit home phone number.
Block 23. Email Address: Enter your email address. (NOTE: If you enter
Block 5. Accreditation Renewal: Check this block if you are renewing
a shared email address, that information may be viewed by others.)
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.
Business Contact Information
Block 6. Post -Revocation Reaccreditation: Check this block if your
Block 24. Name of Business: Enter the name of the business where you
accreditation was revoked and you are applying for reaccreditation.
work/practice. If you are self-employed without a specific business name,
Complete blocks 6, 7, 8, 10, 15/16, 17-33, 37, and 38.
enter your name from Block 7.
Block 7. Name of Veterinarian: Enter your legal last name, first name and
Block 25. Business Mailing Address: Enter complete business mailing
middle initial. (If this is a name change request, enter your new legal name
address. If your home mailing address is your business mailing address,
in this block.) Check the block, if your name has changed and complete
write “Same as home address.”
Block 9.
Block 26. City: Enter the city of your business address.
Block 8. Six-Digit National Accreditation No.: Enter the National
Accreditation Number that you have been assigned.
Block 27. State: Enter the two-letter state abbreviation of your business
address.
Block 9. Other Names Used (e.g., Maiden Name): Enter other names
used – for example, maiden name, nickname (this name should not be the
Block 28. ZIP Code: Enter the five- or nine-digit ZIP code of your business
same name as in block 7).
address.
Block 10. Date of Birth: Enter the two-digit month, two-digit day, and four-
Block 29. County of Business Mailing Address: Enter the county in
digit year of your birth.
which your business address is located.
Block 11. School of Veterinary Medicine: Enter the name of the school
Block 30. Business Phone Number: Enter your 10-digit business phone
of veterinary medicine from which you graduated.
number.
Block 12. Year Graduated: Enter your four-digit year of graduation from a
Block 31. Business Cell Number: Enter your 10-digit cell phone number.
school of veterinary medicine.
Block 32. Business FAX Number: Enter your 10-digit fax number.
Block 13. State where Orientation Completed: Enter the two letter
abbreviation of the State where core orientation was completed.
Block 33. May your business contact information be released to the
public by the USDA? Check "yes" or "no" to having your business
Block 14. Are you interested in participating in State or Federal
contact information released.
agricultural emergency response efforts? Check “yes” or “no”, if you
would like to be contacted to assist with agricultural emergency response
efforts.
Block 34. Module Number: Enter the module numbers, not the names, of
the APHIS approved supplemental training modules you have completed.
Category Selection
Category I veterinarians: three modules; Category II veterinarians: six
(Refer to Explanation of Codes)
modules
Block 15. Category I: Check this block for authorization to only perform
Block 35. Course Type: Enter either Online, Lecture, CD, or Print. The
accredited duties on canines, felines, amphibians/reptiles, furbearing
CD and Print designations indicate that you purchased a CD or printed
animals, laboratory animals (rodents), and/or non-human primates.
version of the module from the Center for Food Security and Public Health
at Iowa State University.
Block 16. Category II: Check this block for authorization to perform
accredited duties on all animals.
Block 36.
Date Module Completed: Enter the two-digit month, two-digit
day, and four-digit year that you completed the module.
Practice Code(s): Enter up to two code(s) which most clearly describes the
species upon which you will perform accredited duties.
Certification/Approval
Species Code(s): Enter up to four code(s) associated with the species with
Block 37. Signature of Veterinarian: Read the certification statement
which you most often expect to perform accredited duties. These entries do
above block 37 and sign in blue or black ink. (NOTE: The applicant MUST
not limit the species on which you may perform accredited duties within
be licensed or legally able to practice as a veterinarian.)
your Accreditation Category.
Primary Medical Discipline: Enter the number associated with the
Block 38. Date: Enter the two-digit month, two-digit day, and four-digit
discipline that best describes your primary medical discipline.
year that you signed this application.
Employment Type: Enter the number associated with your employment
Blocks 39-42: Do not enter any information in these blocks.
type.
VS Form 1-36A
DEC 2013
PRIVACY ACT NOTICE
General:
This 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:
The 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:
Although 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)
9 -
Business/Economics
58 - Other Professional Discipline
(May indicate up to 2 codes)
10 - Cardiology
Employment Type (Blocks 15 & 16)
(“Predominant” = Greater than 50%
11 - Dentistry
(May choose only 1 type)
Species Contact,
12 - Dermatology
Private Clinical Practice
“Exclusive” = Only Species Contact)
13 - Disaster Medicine
1 -
General Medicine/Surgery
1 -
Food Animal Predominant
14 - Ecology
2 -
Production Medicine
2 -
Food Animal Exclusive
15 - Emergency and Critical Care
3 -
Referral/Specialty Medicine
3 -
Companion Animal Predominant
16 - Endocrinology
4 -
Emergency/Critical Care Medicine
4 -
Companion Animal Exclusive
17 - Environmental Health
5 -
Other Private Clinical Practice
5 -
Mixed Animal
18 - Epidemiology
6 -
Equine Predominant
19 - Ethics
Academia
7 -
Equine Exclusive
20 - General Medicine
6 -
Veterinary Medical College/School
8 -
Other
21 - Genetics
7 -
Veterinary Science Department
9 -
No Species Contact
22 - Human Animals Bond
8 -
Veterinary Technician Program
23 - Homeland Security
9 -
Animal Science Department
Species Codes (Blocks 15 & 16)
24 - Immunology
10 - Other Academia
(May choose up to 4 codes)
25 - Internal Medicine
1 -
Canine
26 - Insurance
Government
2 -
Feline
27 - Laboratory Animal Medicine
11 - U.S. Federal
3 -
Equine
28 - Law
12 - State
4 -
Bovine
29 - Media
13 - Local
5 -
Porcine
30 - Microbiology
14 - Foreign
6 -
Ovine/Caprine
31 - Mycology/Bacteriology
15 - Army
7 -
Camelid
32 - Molecular Biology
16 - Air Force
8 -
Cervid
33 - Neurology
17 - Public Health Commission Corps
9 -
Poultry
34 - Non-Medical
18 - Other Government
10 - Avian (non-poultry)
35 - Nutrition
11 - Exotics
36 - Oncology
Industry/Commercial
12 - Amphibian/Reptile
37 - Ophthalmology
19 - Pharmaceutical/Biological
38 - Parasitology
13 - Aquatic Animal
20 - Feeds/Nutrition
14 - Zoo Animal
39 - Pathology - Anatomic
21 - Laboratory
15 - Wildlife
40 - Pathology – Clinical
22 - Agriculture/Livestock Production
16 - Furbearing Animals
41 - Pharmacology
23 - Business/Consulting Services
17 - Laboratory Animal
42 - Pharmacology – Clinical
24 - Other Industry/Commercial
18 - Non-Human Primate
43 - Physiology
19 - Other Species
44 - Population Medicine
Other
20 - No Species Contact
45 - Poultry Medicine
25 - Humane Organization
46 - Preventative Medicine
26 - Membership Assn/Professional
Primary Medical Disciplines
47 - Production Medicine
Society
(Blocks 15 & 16)
48 - Public Health
27 - Foundation/Charitable Organization
(Choose only 1 discipline)
49 - Radiology
28 - Missionary/Service
1 -
Anatomy
50 - Shelter Medicine
29 - Zoo/Aquarium
2 -
Anesthesiology
51 - Sports Medicine
30 - Wildlife
3 -
Animal Behavior
52 - Surgery
32 - Temp Not Employment in Veterinary
53 - Theriogenology
4 -
Animal Welfare
Field
54 - Toxicology
5 -
Alternative/Contemporary
33 - Non-Veterinary Employment
6 -
Association Management
55 - Virology
34 - Not Employed
7 -
Biochemistry
56 - Wildlife Medicine
35 - Not Listed Above
8 -
Biomedical Engineering
57 - Zoological Medicine
This Professional Classification System is used courtesy of the American Veterinary Medical Association.
VS Form 1-36A
DEC 2013
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