Produccer Affid
davit &
Ma
arket Sw
wine Health Reco
ord
Youth Producer:
P
Name:: ____________
_____________
_
Address: __________
_____________
_
___
_____________
_____________
_
Premisse ID (if availablee):___________
_
Phone: ____________
_____________
_
_____________
_
QA Ceertification #: __
Fair: ____________
_____________
_
Fair Taag #: ________
_____________
_
Sale Date:
D
_________
_____________
_
Producerr Affidavit and Animal Inform
mation (Obtain
n from produceer):
Herd Tag
T #/ Ear Notch
h ID:_________
______________
__________ Seex: __________
______________
__
Birth Date:_________
D
____ Breed/Color: __________
__________________________
______________
__
I (origina
al producer) atttest through firrst-hand knowlledge, normal b
business record
ds, or producerr
affidavit((s) that the anim
mal referenced
d to by this docu
ument is of ____________ (counntry) origin, and
d is
delivered
d to __________
_____________
______________
___________________________
___ (Youth Produccer).
Date Purrchased: ______
_________
Premiise ID (if availablle): __________
______________
__
Purchaseed From: _____
_____________
______________
_ (Farm Name) O
Office Phone: ______________
_
__
Address: ____________
______________
__________ Ciity, State, Zip: ____________
______________
__
Producerr Signature ___
_____________
______________
__ Print Name ___________
______________
__
Youth pro
oducers only list treatments
t
admin
nistered while un
nder your care. Do
D NOT list treattments administeered prior to purcchase.
If you neeed additional spa
ace for treatments
ts or medicated feeeds use supplem
mental health form
m page—availab
ble at animalag.w
wsu.edu-“Youth Producers”
P
Treatmen
nts &
Deworm
mers
(Date & Tim
me)
Conditiion Being
Treeated
Estimated
E
Weight
atment Administeered
Trea
(Mediccation dispensed, amoun
nt and
r
route
of administration)
Drug Lot
Number
Name
(Person giving
treatment)
Withdrawal
Time
Withdrawal
Complete
(Instructed)
(Date & Time)
For prescription or extra
he
label drug use, list th
veeterinarian’s name, add
dress,
and phone.
Medicateed Feeds: Rem
member to documeent ALL medicateed feeds and withd
drawal times
Medication Name
N
Dates Fed
(Medication inclu
uded in feed and approx
ximate amount of medication)
wal
Withdraw
Time
Withdrawal
Complete
(Instructed))
(Date & Time)
“Produce healthy
h
and safe pork
products by
y being a
knowledgea
able and
responssible
produccer”
I certify that I produced
d this animal an
nd I have listed ALL products and treatments they received
while in my care/ownerrship and all witthdrawal times have been met. I attest that th
he animal
referred
d to by this docu
ument is of ____
________(country
ry) origin and ra
aised in _______
_______ (countryy).
Givee Subcutaneous (Sub-Q) injectio
ons
undeer loose skin of neck
n
or flanks, usiing
the ttented method. Give
G Intramusscular (IM) injecctions in the neck
k.
If laabel indicates a ch
hoice, use Sub-Q
Q
(undder the skin) injecctions over IM.
NEVER
RInject in
nto
the ham
m or
the loin
n
area.
Youth Siignature:______
_____________
_____________
______________
___________Daate:__________
__
Guardian
n Signature:___
______________
_____________
_____________
___________Daate:___________
_
Authors:: Sarah M. Smith, Jeean Smith, and Jan Bu
usboom
Revised and
d published Novemb
ber 2008
Extension progrrams and employmeent are available to all
a without discrimiination. Evidence off discrimination mayy be reported througgh your local Extension Office.
The information given herein is for educational purposes only.
References to commercial products or trade names are made with the understanding that no discrimination is intended and no endorsement by WSU Extension is implied.