VS Form 6-22: Tuberculosis Test Record 



STATE Enter the State name. 



COUNTY 



Use Federal Information Processing Standards county 

 code. A list for your State can be obtained from the 

 Veterinary Services area office. If you cannot obtain the 

 county code, leave the box blank. Enter the township or 

 section code if applicable. 



HERD OWNER 



Enter the complete name and mailing address of the 

 herd owner. 



HERD NUMBER 



The herd number is assigned by your State. If this is a 

 retest, you should know the number. If this is an initial 

 test, you may not know the number. 



LESION, TEST D-B, and U blocks [Leave blank.] 



TOWNSHIP OR DISTRICT 



Fill in names of county, township, or district, section, 

 and farm number, as applicable. (Some States have of- 

 ficial farm numbers. It this is true in your State, the 

 numbers can be obtained from the Veterinary Services 

 area office in your State.) 



REASON FOR TEST 



Mark the appropriate box. If you mark OTHER, state 

 the reason. 



PREVIOUS TEST DATE 



Complete this block only if this is a retest. The Vet Code 

 is assigned by your State. 



COMPLETE HERD TEST OF ALL ELIGIBLE ANIMALS 



Mark yes or no. Provide the total number of animals in 

 the herd. 



KIND OF HERD Mark the appropriate box. 



METHOD OF TEST Mark the appropriate box. 



SUMMARY 



Complete this block after testing. Fill in the number of 

 animals in each category. 



CERTIFICATION FOR PAYMENT 



Mark the appropriate box. 



SIGNATURE, AGREE. CODE 



This is a legal document; be sure to sign it. Your agree- 

 ment code is assigned by your State. 



16-16 



INJECTION, OBSERVATION 



List the date and time that the injection was made and 

 the date and time that the test was read (OBSERVATION). 



REACTORS TAGGED AND BRANDED, AGREE. CODE 



Enter the signature and agreement code of the veteri- 

 narian tagging and branding any reactors. This person 

 may be different from the one filling out the rest of the 

 form. Include the date of tagging and branding. 



ANIMAL CODE 



Enter one of the codes listed at the bottom of the col- 

 umn for all appropri^^ate animals. 



IDENTIFICATION NUMBER 



Record permanent identification, e.g., metal eartags 

 and tattoos. If more than one is present, record them 

 all. If none is present, apply metal eartag and record 



that number. 



AGE I^ecord the age in years. 



BREED 



Use the two-digit breed codes listed in table 3. 



SEX Enter M (male), F (female), or N (neuter). 



RESULTS 



Record the diameter of the indurated area in millime- 

 ters in the first column. Record the result of the test in 

 the second column: N (negative) or S (suspect). 



REACTOR TAG NUMBER 



It reactors are present, record the reactor tag 

 number applied. 



DATE, OWNER'S SIGNATURE 



Have the owner sign and date the form. Leave part 3 

 (third sheet of the form ) with the owner. 



THIS AUTHORIZATION TO TEST EXPIRES 



Enter the date. It is determined by each State and may 

 vary depending on the circumstances. Check with your 

 State Veterinarian's office. 



After completing the form, send parts 1, 2, and 5 to the 

 State or Veterinary Services area office (check with your 

 State), give part 3 to the owner, and keep part 4 jor 

 your records. 



