State, Tribal, Local Gov't

OMB Approved, 0579-XXXX, exp XX/XXXX

US Swine Health Improvement Plan

Piloting a proven platform for safeguarding, certifying, and bettering animal health

Single Premises US SHIP Enrollment Form
State of Participation (location of participating premises): _________________________________
Participants are to enroll with each US SHIP OSA in which they have participating facilities located.

Swine Owner Information (US SHIP Participant)
Name (Business Entity): ___________________________________________________________________
Address: _____________________________________________________________________________
Address
City
State
Zip
Phone Number: ______________________ Email: ___________________________________________

Premises (Site) Information
Premises Identification Number (PIN): _____________________________________________________
Common Name of Site (if different than Swine Owner Name): ________________________________________
911 Address of Site: ____________________________________________________________________
Address
City
State
Zip
GPS Coordinates (if 911 address not assigned) Latitude: _________________ Longitude: _________________
Site Type:
☐ Boar Stud - Production site with mature boars that distribute semen to other production sites.
☐ Breeding Herd - Production site with breeding females and house ≥ 1,000 breeding swine (e.g., breed-to-wean,
breeding/gestation or farrowing only, with or without on-site gilt isolation/grow-out).

☐ Growing Pigs - Production site with ≥ 1,000 feeder swine (nursery, grower, or finisher).
☐ Farrow to Feeder/Finish - Production site with breeding females and grow feeder swine for purposes other than

breeding stock replacement for this particular farm site, and house ≥ 1,000 breeder or
feeder swine.
☐ Small Holding - Production sites with ≥ 100 and < 1,000 total breeder or feeder swine.
☐ Non-Commercial - Production sites with < 100 pigs (e.g., exhibition, niche, hobby)

☐ Packing Plant - A facility that slaughters pigs.
☐ Live Animal Marketing Operation - A dealer with a livestock yard/buying station (facility) that markets > 100
swine/week for resale of such swine to slaughter facilities.

Site Capacity: _________________________________________________________________________

Premises (Site) Owner Information
☐ Same as Swine Owner Contact (US SHIP Participant)
If different, please complete below:
Name: _______________________________________________________________________________
Address: _____________________________________________________________________________
Address
City
State
Zip
Phone Number: ______________________ Email: ___________________________________________
Version 3 – 5/2024

US Swine Health Improvement Plan

Piloting a proven platform for safeguarding, certifying, and bettering animal health

Acknowledgment of Participant Understanding & Compliance
Name and Contact Information for the Individual Submitting Acknowledgment
☐ Same as Swine Owner Contact (US SHIP Participant) on Page 1
If different, please complete below:
Name: ____________________________________________________________________________
Relationship to Swine Owner (US SHIP Participant): _______________________________________
Phone Number: _______________________ Email: _______________________________________
☐ I can attest to this US SHIP program participant’s understanding of the relevant program standards and
good-faith efforts to be compliant with the requirements of the US SHIP certification(s) held.
☐ I acknowledge that the US SHIP program standards are expected to evolve over time. It is the
responsibility of the program participants to meet or exceed the requirements for the US SHIP
certifications they elect to maintain.
☐ As a US SHIP participant, I grant permission for the US SHIP OSA to share the PIN(s) and Status of
US SHIP Health Certifications for the premises of which I have enrolled to the US SHIP Site Status
Verification Database.

Date: ______________________________________________________________________________

Paperwork Reduction Act Disclosure
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 15 to 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.

Version 3 – 5/2024