Aphis Form 7001 - United States Interstate And International Certificate Of Health Examination For Small Animals
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1According to t he P aperwork R eduction Act o f 1995, an ag ency ma y not cond uct or sponsor, an d a p erson i s not r equired to r espond to , a c ollection of
No dog, cat, nonhuman primate, or additional kinds or classes of animals designated by
OMB APPROVED
information unless it displays a valid OMB control number. The valid OMB control numbers for this information collection are 0579-0036 and 0579-0333.
USDA r egulation sh all be del ivered to
any i ntermediate handler or car rier for
0579-0036
The ti me r equired to complete t his i nformation col lection i s esti mated t o av erage .25 h ours per r esponse, i ncluding the ti me for rev iewing in structions,
transportation i n com merce, u nless acco mpanied by a heal th ce rtificate ex ecuted a nd
0579-0333
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
issued by a licensed veterinarian (7 U.S.C. 21.43.9; CFR, Subchapter A, Part 2).
WARNING: Anyone who makes
1. TYPE OF ANIMAL SHIPPED (select one only)
2. CERTIFICATE NUMBER - OFFICIAL USE ONLY
a false, fictitious, or fraudulent
UNITED STATES DEPARTMENT OF AGRICULTURE
Dog
Cat
Other_________________
statement on this document, or
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
uses such document knowing it
Nonhuman Primate
Ferret
Rodent
to be false, fictitious, or
UNITED STATES INTERSTATE AND INTERNATIONAL
fraudulent may be subject to a
CERTIFICATE OF HEALTH EXAMINATION
3. TOTAL NUMBER OF ANIMALS
4. PAGE
fine of not more than $10,000 or
FOR SMALL ANIMALS
imprisonment of not more than 5
years or both (18 U.S.C. 1001).
5. NAME, ADDRESS, AND TELEPHONE NUMBER OF OWNER (CONSIGNOR)
6. NAME, ADDRESS, AND TELEPHONE NUMBER OF RECIPIENT AT DESTINATION (CONSIGNEE)
USDA License/or Registration Number (if applicable)
7. ANIMAL IDENTIFICATION
8. PERTINENT VACCINATION, TREATMENT, AND TESTING HISTORY
COLOR OR
RABIES VACCINATION
OTHER VACCINATIONS,
BREED – COMMON
NAME, AND/OR TATTOO NUMBER
DISTINCTIVE
TREATMENT, AND/OR TESTS AND RESULTS
OR SCIENTIFIC
AGE
SEX
OR OTHER IDENTIFICATION
MARKS OR
1 YEAR
2 YEARS
3 YEARS
NAME
MICROCHIP
Vaccination Date
Product
Date
Product Type and/or Results
(1)
(2)
(3)
(4)
(5)
(6)
9. REMARKS OR ADDITIONAL CERTIFICATION STATEMENTS (WHEN REQUIRED)
VETERINARY CERTIFICATION: I certify that the animals described in box 7 have been examined by me this date, that the
information provided in box 8 is true and accurate to the best of my knowledge, and that the following findings have been made
(“X” applicable statements).
I have verified the presence of the microchip, if a microchip is listed in box 7.
I certify that the animal(s) described above and on continuation sheet(s), if applicable, have been inspected by me on this date and
appear to be free of any infectious or contagious diseases and to the best of my knowledge, exposure thereto, which would endanger the
animal or other animals or would endanger public health.
To my knowledge, the animal(s) described above and on continuation sheet(s) if applicable, originated from an area not quarantined
for rabies and has/have not been exposed to rabies.
ENDORSEMENT FOR INTERNATIONAL EXPORT (IF NEEDED)
NAME, ADDRESS, AND TELEPHONE NUMBER OF ISSUING VETERINARIAN
LICENSE NUMBER AND STATE
PRINTED NAME OF USDA VETERINARIAN
Accredited
Yes
No
If yes, please complete below
NATIONAL ACCREDITATION NUMBER
NOTE: International shipments may require certification by an accredited veterinarian.
SIGNATURE OF USDA VETERINARIAN
DATE
SIGNATURE OF ISSUING VETERINARIAN
DATE
Apply USDA Seal or Stamp here
APHIS Form 7001
(NOV 2010)
This certificate is valid for 30 days after issuance
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