













ALL INCOMPLETE RECORDS WILL BE RETURNED FOR COMPLETION 



STATE 



COOPERATIVE STATE-FEDERAL BRUCELLOSIS ERADICATION PROGRAM L 



BRUCELLOSIS TEST RECORD 



COUNTY 



JCODE 



HERO NUMBER 



HERD OWNER LAST FIH^T INITIAL 



PREVIOUS 

 TEST DATE 



VET CODE 



TOTAL 



REA 



SUS 



OWNER NUMBER 



ROUTE STREETHOAO 



CERTIFICATION FOR PAYMENT 



FEDERAL FEE SIAIE PRIVATE 

 EMPLOYEE BASIS COUNTY 1 Owner $ 



TEST 



PROG 



WBBS 



POST OFFICE STATE ZIP CODE 



1 1 1 ]lf'<l""l 1 1 1 \e,p.nitj 



1 C9Tl,fy 



That 1 have drawn blood samples Irom each animal identilied below and have 



REASON FOR TEST \~\ 



INITIAL 1 IrETEST 



RGE 



TWP 



SEC 



DISTRICT 



FARM UNIT 



coireclly listed each lube number with complete correspondmg i 

 number, all numbers and letters ol all eartags have been listed, c 

 existing olUcial eartags have not been retagged. and when paym 

 at program expense in accordance with agreement number belo 



dentilicBlion 

 atlle with 



Sliughltf ' 





Hd Cert / 6 

 Vahdalioo 





ent IS claimed 

 V. no oavment 





COMPLETE HERO TEST OF 



SUMMARY 



has been or will be received Irom any other source. 



Lvsl Mkl ^ 





Poil Move ' 

 Quae « Teal 





Re> 







NEG- 

 ATIVE 





SIGNATURE 



AGREE CODE 



Suto Rinfl 3 





8 

 Area Teal 





□ vES^NO 







Teit 





NO IN HERD 





4 

 Oiagnoatic 





9 



Epidemiology 





KINO OF HERD 

 □ dairy □beef Qmi.eO 



SUS 

 PECT 





ROUTE STREET ROAO 



DATE BLEO 



Pvi Sale 





Oiner 10 

 iSptcify btlowj 





□ swiNE Qo 



THER /SprC''v 



REAC- 

 TOR 





POST OFFICE STATE ZIP CODE 



FIELD TEST 

 DONE BY 



REMARKS 





LAB ORATOR 









PLACE 



DATE 



TOTAL 





REACTORS TAGGED AND BRANDED 

 DATE SIGNATURE 



1 



AGREE CODE 



DATE LISTED | | | 



ST 



SEX 



FLO 

 T 



LABORATORV RESULTS 



TEST 

 In- 

 itio 



REMARKS 



AND 

 ADDITIONAL 

 INFORMATION 



REACTOR 

 TAG NUMBER 



TUBE 

 NO 



2 



RECORD ALL 



IDENTIFICATION 



NUMBERlSl 



VACC 

 TATTOO 



AGE 



BREED 



BAP A, 



^ST 



CARD 



sn , 



RIV 



CF 









1 



































1 



































3 



































4 



































5 



































6 



































7 



































B 



































9 



































to 



































11 



































12 



































13 



































14 



































IS 































/\ 



/\ 



/\ 



y\ 



/\ 



RT - Relao AB - Aborter 

 NA - Natural Addition 

 PA - Purchased Addition 



Record ALL 

 Earlag(i) and 

 Tanoo(a) 



Record ALL 



Laglbia 



CharacUra 



N - Negative 

 P - Positive 



TEST INTERPRETATION 



N - Negative Classified by 



S - Suspect 



R - Reactor Dale Classified 



TEST 



AUTHORIZATION 



EXPIRES 



VS FORM 4-33 

 (FEB 92) 



Replaces edition date ol (4/8 1). which maybe used. 



PART1-CF»^»CE 



16-12 



