VS 12-2 HPAI H5N1 Milk Silo Submission Form

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
NATIONAL VETERINARY SERVICES LABORATORIES
1920 DAYTON AVENUE, AMES, IA 50010
515-337-7266

HPAI H5N1 MILK SILO SUBMISSION
FORM

1. SUBMITTER INFORMATION
NAME (Including Business Name)

PREMISES ID:

EMAIL ADDRESS (For results reports)

4. COLLECTED BY

MAILING ADDRESS (Street, City, State, ZIP Code)

9. SAMPLE INFORMATION
SAMPLE NO. (BAR CODE)

PHONE NUMBER

5. DATE COLLECTED:

FAX NUMBER

8. TOTAL NUMBER OF SAMPLES SUBMITTED

IDENTIFICATION (BTU numbers)

OMB Approved
0579-XXXX
Exp. XX/XXXX
PAGE
OF

COMMENTS:

DATE COLLECTED:
SAMPLE NO. (BAR CODE)

IDENTIFICATION (BTU numbers)

COMMENTS:

SAMPLE NO. (BAR CODE)

IDENTIFICATION (BTU numbers)

COMMENTS:

DATE COLLECTED:
SAMPLE NO. (BAR CODE)

IDENTIFICATION (BTU numbers)

COMMENTS:

DATE COLLECTED:
SAMPLE NO. (BAR CODE)

IDENTIFICATION (BTU numbers)

COMMENTS:

DATE COLLECTED:
SAMPLE NO. (BAR CODE)

IDENTIFICATION (BTU numbers)

COMMENTS:

DATE COLLECTED:

10: SIGNATURE OF COLLECTOR AND DATE: I certify that samples were collected according to the USDA National Silo Monitoring plan.

11. ADDITIONAL DATA (Remarks, special instructions. Use additional sheets, if necessary).

VS FORM 12-2
DEC 2024

LABORATORY USE ONLY

VS FORM 12-2 INSTRUCTIONS

ALL information must be printed legibly or typed. Use a
separate form for each owner. At the minimum, complete all
fields designated in these instructions as required. Contact
the Receiving Department of the laboratory to which you are
sending specimens with specific documentation or shipping
questions.
If including more than one page, include the page number of
total pages submitted (e.g., 1 of 3).
1. SUBMITTER CONTACT INFORMATION

“REQUIRED”

Enter the submitter’s business name/affiliation; the name of
the individual submitter is optional if test results are returned
to a general business email. Enter an email address to
which APHIS can return test results. Multiple email
addresses are permissible. Provide a complete mailing
address. If email is not available, test reports may be
mailed, but this will delay delivery of results and may incur a
fee. Repeat submitters are encouraged to be consistent with
the submitter contact information that is provided, as the
NVSL keeps a master record
4. COLLECTED BY
Enter the complete name of the person collecting the
specimen(s).
5. DATE COLLECTED
Enter the date on which specimens were collected. Use the
format DD/MM/YYYY. If samples were collected on different
days, write the sample collection date in the comments
section for each sample.
8. TOTAL NUMBER OF SAMPLES SUBMITTED
“REQUIRED”
Enter the total number of samples submitted from this farm.
9. SAMPLE INFORMATION
Collect samples in vials provided by the National Veterinary
Services Laboratories. Use provided bar codes and place
one barcode on the tube of milk and one on the VS-XX form
under Sample No.
Enter the BTU numbers associated with the sample. Ensure
the complete BTU number, including the state code is used.
10. SIGNATURE OF COLLECTOR AND DATE
Ensure the sample collector signs the form verifying the
samples were collected according to the USDA National Silo
Monitoring plan.
11. ADDITIONAL DATA
Enter pertinent information that can assist the lab.
• Provide detail on collections as needed
• Include any information that did not fit into its designated
space elsewhere on the form.
• Include any special (non-standard) instructions for test
report delivery