VS 12-3 HPAI H5N1 Mandatory USDA Silo Monitoring Supply Order Fo

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-XXXX. The time required to complete this
information collection is estimated to average 30 minutes 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. Send comments regarding this burden statement or any other aspect of this
information collection, including suggestions for reducing this burden, to APHIS.PRA@usda.gov.

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION
SERVICE VETERINARY SERVICES
Contact Name:

OMB Approved
0579-XXXX
Exp. XX/XXXX

MANDATORY USDA SILO MONITORING SUPPLY ORDER FORM

Shipping Address (Do not use a PO Box) City, State,
Zip code:
Phone Number:

Email:

Date of Request:
Requesting supplies: Each diagnostic shipper can hold up to 60 samples, 30 per box. Collectors may hold samples at
refrigerator temperature (4oC) for no longer than four days before shipping. While NVSL can receive samples on
Saturday, shipping Monday - Thursday is preferred. If possible, order enough supplies for 2-4 months of sampling at a
time.
Bulk Collection supplies

Amount
Per Unit

Small Diagnostic Shipper
Cardboard 40 short insert box
w/insert.
Yellow screw cap collection tubes (10
mL)
Individually wrapped transfer
pipettes (5 mL)
AI Bar codes (4 repeats per number)

1
1

Large sealable bag - 32035
Freezer Gel Packs
Absorbent pads - 68083
Prepaid FedEx Shipping Labels to
NVSL (Only available 1 pack at a time
- NVSL can email additional labels as
needed)
Prepaid FedEx Shipping Labels to
NVSL (emailed to requester)
Milk silo submission forms

25/roll
36/case
250/pack
10/pack

No Units
Individual collection kits
Requested
Each collection kit contains:
1 Small diagnostic shipper
2 cardboard 40 short tube boxes

100/bag
100/bag
10/pack

Request via the email
below
1

All orders are required to be submitted using this form.
Email completed form to: NVSLShipping@usda.gov

VS FORM 12-3
DEC 2024

100 screw cap collection tubes
(10 mL)
100 Individually wrapped transfer
pipettes (5 mL)
100 sets of bar codes (4 labels per
code)
1 Large sealable bag
1 Freezer Gel Pack
2 Absorbent pads
1 Prepaid FedEx Return Shipping
label to NVSL
1 Milk silo submission form
Number of complete collection
kits requested:

Quantity