21 



(Blood Collector's Questionnaire ) 



INFORMATION REGARDING FLOCKS TESTED FOR DETECTION 

 OF SALMONELLA PULLORUM INFECTION 



Please make careful observations at each poultry plant, and fill 

 out to the best of your ability and return at the end of the week 

 with your expense voucher. This information is intended for the 

 purpose of aiding us in helping the flock owner and is strictly 

 confidential. 



Blood Collector Date of Collection., 



Flock Owner 



Original Source of Stock 



Source and kind of stock added since last previous test 



Does the owner trapnest? Do custom hatching? 



Make of incubator used 



Mortality from B. W. D. in chicks last spring 



Number of birds on place not bled: Chickens Other fowl- 

 Number of reactors kept on farm since last test Purpose 



How were they isolated? 



"Were there any reactors from previous tests bled at this time? 



( )ther fowl than chickens raised 



Cooperation 



Does the flock owner want a retest this season? 



Condition of Plant - 



Dirt floors 



Ventilation „.... 



Outside runs 



Condition of Flock 



Litter 



Dropping boards 



Type of houses 



Further Remarks: 



