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

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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.

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

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

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

Practice Code(s):

(select up to two)

Practice Code(s):

_______

(list up to two)

Species Code(s):

17 (rodents)

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

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

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

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

Practice Code(s):

(select up to two)

Practice Code(s):

_______

(list up to two)

Species Code(s):

17 (rodents)

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

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

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

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

What Is VS Form 1-36a?

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