Form 36A Form Details

MRI medical forms are an important part of the diagnostic process. They help to provide healthcare professionals with all of the information they need in order to make a diagnosis. The blank MRI medical form is a tool that can be used to collect this information. It is important to understand how to use and complete the form correctly in order to get the most accurate results. This blog post will provide you with all of the information you need to know about MRI medical forms and blank MRI medical forms specifically. You will learn what the purpose of each section is and how to fill it out correctly. By understanding these forms, you can ensure that your doctor has all of the information he or she needs in order to make an accurate diagnosis.

This table has got details about blank mri medical form. Before you decide to fill in the form, it is worth checking more details on it.

QuestionAnswer
Form NameBlank Mri Medical Form
Form Length4 pages
Fillable?Yes
Fillable fields89
Avg. time to fill out18 min 52 sec
Other names1 nvap block, vs 1 36a, form 1 program, form 1 program form

Form Preview Example

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

UNITED STATES DEPARTMENT OF AGRICULTURE

 

1.

Initial Accreditation

 

2. Authorization in a new State

 

 

 

 

 

 

 

 

 

 

 

 

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:

 

 

 

 

 

 

 

13. State where First Orientation Completed:

 

 

 

 

14. Are you interested in participating in State or Federal agricultural emergency response

efforts?

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACCREDITATION CATEGORY SELECTION select only one – Block 15 OR 16

15.Category I animals (includes canines, felines, amphibians/reptiles, furbearing animals, laboratory animals (rodents), and non-human primates)

Refer to Explanation of Codes Page

Practice Code(s):

3

4

8

9 (select up to two)

 

Species Code(s):

1

2

12

16

17 (rodents)

18

(select up to four;

this does not limit the number of Category I species upon which you may

perform accredited duties)

 

 

 

 

 

Primary Medical Discipline:

_______

 

 

 

 

Employment Type:

 

_______

 

 

 

 

16. Category II animals (includes all animals)

Refer to Explanation of Codes Page

Practice Code(s):

_______

_______

(list up to two)

Species Code(s): _____

_____ ______

_____

(list up to four; this does not limit the

 

 

 

number of species upon which you

 

 

 

may perform accredited duties)

Primary Medical Discipline:

_______

 

 

Employment Type:

_______

 

 

CONTACT INFORMATION

17. Home Mailing Address:

24. Name of Business:

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:

41.Signature of Veterinarian-in-Charge:

40.Date:

42.Date:

VS Form 1-36A

Previous edition may be used

DEC 2013

 

Instructions for Completing VS Form 1-36A, National Veterinary Accreditation Program (NVAP) Application.

Block 1. Initial Accreditation: Check this block if you are applying for initial accreditation. Enter the two-letter State abbreviation and your complete veterinary license number for this State. Complete blocks 1, 7, 9 (if applicable), 10, 11, 12, 13, 14, 15/16, 17-33, 37, and 38.

Block 2. Authorization in a new State: Check this block if you are seeking authorization to perform accredited duties in an additional State. Enter the two-letter State abbreviation and your complete veterinary license number for this State. Complete blocks 2, 7, 8, 9 (if applicable) 10, 17-33, 37, and 38.

Block 3. Change Accreditation Category: Check this block if you are changing your Accreditation Category. Complete blocks, 3, 7, 8, 10, 15/16, and 34-38.

Block 4. Contact Information Change: Check this block if you are changing your contact information (e.g., name, address). Complete blocks 4, 7, 8, 10, 37, 38, and the appropriate CONTACT INFORMATION fields.

Block 5. Accreditation Renewal: Check this block if you are renewing 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.

Block 6. Post -Revocation Reaccreditation: Check this block if your accreditation was revoked and you are applying for reaccreditation. Complete blocks 6, 7, 8, 10, 15/16, 17-33, 37, and 38.

Block 7. Name of Veterinarian: Enter your legal last name, first name and middle initial. (If this is a name change request, enter your new legal name in this block.) Check the block, if your name has changed and complete Block 9.

Block 8. Six-Digit National Accreditation No.: Enter the National Accreditation Number that you have been assigned.

Block 9. Other Names Used (e.g., Maiden Name): Enter other names used – for example, maiden name, nickname (this name should not be the same name as in block 7).

Block 10. Date of Birth: Enter the two-digit month, two-digit day, and four- digit year of your birth.

Block 11. School of Veterinary Medicine: Enter the name of the school of veterinary medicine from which you graduated.

Block 12. Year Graduated: Enter your four-digit year of graduation from a school of veterinary medicine.

Block 13. State where Orientation Completed: Enter the two letter abbreviation of the State where core orientation was completed.

Block 14. Are you interested in participating in State or Federal agricultural emergency response efforts? Check “yes” or “no”, if you would like to be contacted to assist with agricultural emergency response efforts.

Category Selection

(Refer to Explanation of Codes)

Block 15. Category I: Check this block for authorization to only perform accredited duties on canines, felines, amphibians/reptiles, furbearing animals, laboratory animals (rodents), and/or non-human primates.

Block 16. Category II: Check this block for authorization to perform accredited duties on all animals.

Practice Code(s): Enter up to two code(s) which most clearly describes the species upon which you will perform accredited duties.

Species Code(s): Enter up to four code(s) associated with the species with which you most often expect to perform accredited duties. These entries do not limit the species on which you may perform accredited duties within your Accreditation Category.

Primary Medical Discipline: Enter the number associated with the discipline that best describes your primary medical discipline.

Employment Type: Enter the number associated with your employment type.

Home Contact Information

Block 17. Home Mailing Address: Enter your complete home mailing address. This is the address that will be used by NVAP to communicate with you.

Block 18. City: Enter the city of your home address.

Block 19. State: Enter the two-letter state abbreviation of your home address.

Block 20. ZIP Code: Enter the five- or nine-digit ZIP code of your home address.

Block 21. County of Home Mailing Address: Enter the county in which your home address is located.

Block 22. Home Phone: Enter your 10-digit home phone number.

Block 23. Email Address: Enter your email address. (NOTE: If you enter a shared email address, that information may be viewed by others.)

Business Contact Information

Block 24. Name of Business: Enter the name of the business where you work/practice. If you are self-employed without a specific business name, enter your name from Block 7.

Block 25. Business Mailing Address: Enter complete business mailing address. If your home mailing address is your business mailing address, write “Same as home address.”

Block 26. City: Enter the city of your business address.

Block 27. State: Enter the two-letter state abbreviation of your business address.

Block 28. ZIP Code: Enter the five- or nine-digit ZIP code of your business address.

Block 29. County of Business Mailing Address: Enter the county in which your business address is located.

Block 30. Business Phone Number: Enter your 10-digit business phone number.

Block 31. Business Cell Number: Enter your 10-digit cell phone number.

Block 32. Business FAX Number: Enter your 10-digit fax number.

Block 33. May your business contact information be released to the public by the USDA? Check "yes" or "no" to having your business contact information released.

Block 34. Module Number: Enter the module numbers, not the names, of the APHIS approved supplemental training modules you have completed. Category I veterinarians: three modules; Category II veterinarians: six modules

Block 35. Course Type: Enter either Online, Lecture, CD, or Print. The CD and Print designations indicate that you purchased a CD or printed version of the module from the Center for Food Security and Public Health at Iowa State University.

Block 36. Date Module Completed: Enter the two-digit month, two-digit day, and four-digit year that you completed the module.

Certification/Approval

Block 37. Signature of Veterinarian: Read the certification statement

above block 37 and sign in blue or black ink. (NOTE: The applicant MUST be licensed or legally able to practice as a veterinarian.)

Block 38. Date: Enter the two-digit month, two-digit day, and four-digit year that you signed this application.

Blocks 39-42: Do not enter any information in these blocks.

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

 

 

(May indicate up to 2 codes)

10

- Cardiology

 

(“Predominant” = Greater than 50%

11

- Dentistry

 

 

Species Contact,

12

- Dermatology

“Exclusive” = Only Species Contact)

13

- Disaster Medicine

1 -

Food Animal Predominant

14

- Ecology

2 -

Food Animal Exclusive

15

- Emergency and Critical Care

3 -

Companion Animal Predominant

16

- Endocrinology

4 -

Companion Animal Exclusive

17

- Environmental Health

5 -

Mixed Animal

18

- Epidemiology

6 -

Equine Predominant

19

- Ethics

7 -

Equine Exclusive

20

- General Medicine

8 -

Other

21

- Genetics

9 -

No Species Contact

22

- Human Animals Bond

 

 

 

23

- Homeland Security

Species Codes (Blocks 15 & 16)

24

- Immunology

 

 

(May choose up to 4 codes)

25

- Internal Medicine

1 -

Canine

26

- Insurance

2 -

Feline

27

- Laboratory Animal Medicine

3 -

Equine

28

- Law

4 -

Bovine

29

- Media

5 -

Porcine

30

- Microbiology

6 -

Ovine/Caprine

31

- Mycology/Bacteriology

7 -

Camelid

32

- Molecular Biology

8 -

Cervid

33

- Neurology

9 -

Poultry

34

- Non-Medical

10

-

Avian (non-poultry)

35

- Nutrition

11

- Exotics

36

- Oncology

12

- Amphibian/Reptile

37

- Ophthalmology

13

- Aquatic Animal

38

- Parasitology

14

- Zoo Animal

39

- Pathology - Anatomic

15

-

Wildlife

40

- Pathology – Clinical

16

- Furbearing Animals

41

- Pharmacology

17

- Laboratory Animal

42

- Pharmacology – Clinical

18

- Non-Human Primate

43

- Physiology

19

- Other Species

44

- Population Medicine

20

- No Species Contact

45

- Poultry Medicine

 

 

 

46

- Preventative Medicine

Primary Medical Disciplines

47

- Production Medicine

(Blocks 15 & 16)

48

- Public Health

(Choose only 1 discipline)

49

- Radiology

1 -

Anatomy

50

- Shelter Medicine

2 -

Anesthesiology

51

- Sports Medicine

3 -

Animal Behavior

52

- Surgery

4 -

Animal Welfare

53

- Theriogenology

5 -

Alternative/Contemporary

54

- Toxicology

6 -

Association Management

55

- Virology

7 -

Biochemistry

56

- Wildlife Medicine

8 -

Biomedical Engineering

57

- Zoological Medicine

58 - Other Professional Discipline

Employment Type (Blocks 15 & 16) (May choose only 1 type)

Private Clinical Practice

1 - General Medicine/Surgery

2 - Production Medicine

3 - Referral/Specialty Medicine

4 - Emergency/Critical Care Medicine

5 - Other Private Clinical Practice

Academia

6 - Veterinary Medical College/School

7 - Veterinary Science Department

8 - Veterinary Technician Program

9 - Animal Science Department

10 - Other Academia

Government

11 - U.S. Federal

12 - State

13 - Local

14 - Foreign

15 - Army

16 - Air Force

17 - Public Health Commission Corps

18 - Other Government

Industry/Commercial

19 - Pharmaceutical/Biological

20 - Feeds/Nutrition

21 - Laboratory

22 - Agriculture/Livestock Production

23 - Business/Consulting Services

24 - Other Industry/Commercial

Other

25 - Humane Organization

26 - Membership Assn/Professional

Society

27 - Foundation/Charitable Organization

28 - Missionary/Service

29 - Zoo/Aquarium

30 - Wildlife

32 - Temp Not Employment in Veterinary

Field

33 - Non-Veterinary Employment

34 - Not Employed

35 - Not Listed Above

This Professional Classification System is used courtesy of the American Veterinary Medical Association.

VS Form 1-36A

DEC 2013

How to Edit Blank Mri Medical Form

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accreditation form veterinary gaps to fill in

In the Yes, Module Number, Course Type, ACCREDITATION RENEWAL OR CHANGE OF, Enter the module numbers, Category I veterinarians: three, Date Module Completed, and By signing in block 37 area, put in writing your data.

Entering details in accreditation form veterinary part 2

It's essential to highlight the fundamental particulars in the By signing in block 37, Signature of the, VS Form 1-36A DEC 2013, and Previous edition may be used section.

Filling in accreditation form veterinary step 3

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