Form 77 043 PDF Details

The 77 043 form, officially recognized under the guidance of the Paperwork Reduction Act of 1995, plays a crucial role in the interstate and international transport of animals, ensuring both their health and legal compliance. Governed by a pair of valid OMB control numbers, 0579-0020 and 0579-0036, this form mandates the acquisition of a health certificate executed by a licensed veterinarian for the movement of dogs, cats, nonhuman primates, and other animals as specified by the USDA regulations, through any intermediate handler or carrier involved in commerce. Estimations suggest the completion of this information collection takes between .13 to .25 hours, encompassing a review of instructions, the search of existing data sources, and the assimilation and examination of needed data. The form serves as a safeguard, imposing severe penalties for any false, fictitious, or fraudulent statements, with consequences including fines up to $10,000 or imprisonment for no more than five years. Detailing the type of animal shipped, certificate numbers for official use, a comprehensive identification including breed, age, sex, distinctive marks or microchip numbers, and a record of pertinent vaccination, treatment, and testing history, the form ensures each animal’s health status is thoroughly documented. Moreover, it includes spaces for remarks or additional certification statements when necessary, alongside the veterinary certification confirming the animal's disease-free status and lack of exposure to contagious conditions, backed by the veterinarian's signature and accreditation details. Significantly, for international exports, an additional endorsement and the USDA veterinarian's seal or stamp are required, reaffirming the certificate's validity for 30 days post-issuance. Through these measures, the 77 043 form serves as a critical document in upholding public health standards and animal welfare during transportation.

QuestionAnswer
Form NameForm 77 043
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesca movement information, animal movement information, ca general movement information, ca movement information search

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

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 0579-0020 and 0579-0036.

USDA regulations shall be delivered to any intermediate handler or carrier for transportation

0579-0020

The time required to complete this information collection is estimated to average .13 to .25 hours per response, including the time for reviewing instructions,

in commerce unless accompanied by a health certificate executed and issued by a licensed

0579-0036

searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

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

UNITED STATES DEPARTMENT OF AGRICULTURE

a false, fictitious, or fraudulent

 

Dog

Cat

Other_________________

 

ANIMAL AND PLANT HEALTH INSPECTION SERVICE

statement on this document, or

 

 

 

 

 

 

 

 

 

uses such document knowing it

 

Nonhuman Primate

Ferret

Rodent

 

UNITED STATES INTERSTATE AND INTERNATIONAL

to be false, fictitious, or

 

 

 

 

 

 

 

 

CERTIFICATE OF HEALTH EXAMINATION

fraudulent may be subject to a

 

 

 

 

 

 

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

 

 

NAME, AND/OR TATTOO NUMBER

BREED – COMMON

 

 

COLOR OR

 

 

RABIES VACCINATION

 

 

OTHER VACCINATIONS,

 

OR SCIENTIFIC

AGE

SEX

DISTINCTIVE

 

 

 

 

 

TREATMENT, AND/OR TESTS AND RESULTS

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 Apply USDA Seal or Stamp here

DATE

 

SIGNATURE OF ISSUING VETERINARIAN

 

 

 

 

 

DATE

APHIS Form 7001

 

(NOV 2010)

This certificate is valid for 30 days after issuance

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You have to provide the necessary details in the REMARKS OR ADDITIONAL, ENDORSEMENT FOR INTERNATIONAL, VETERINARY CERTIFICATION I certify, I have verified the presence of, I certify that the animals, appear to be free of any, To my knowledge the animals, for rabies and hashave not been, LICENSE NUMBER AND STATE, Accredited Yes No If yes please, NATIONAL ACCREDITATION NUMBER, SIGNATURE OF USDA VETERINARIAN, DATE, NOTE International shipments may, and DATE field.

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