According lo the PaperworV Reduction Act o* 1 995. no persons are required to respond to a collection ot information unless it displays a valid 0MB control number. The valid 0MB control number (or this 

 information collection is 0579-0084. The lime required to complete this intormation collection is estimated lo average .3 hours per response, including ihe time tor reviewing instructions, search existing data 

 sources, gathenng and maintaining the data needed, and completing and reviewing the collection ot information. 



STATE 



ALL INCOMPLETE RECORDS WILL BE RETURNED FOR COMPLETION 

 COOPERATIVE STATE - FEDERAL TUBERCULOSIS ERADICATION PROGRAM 



TUBERCULOSIS TEST RECORD 



FORM APPROVED 

 OMB NO 0579-OOM 



COUNTY 



TWP SEC 



HERO OWNER S NAME - 



LAST 





FIRST 









Ml 



PREVIOUS TEST DATE 



i VET CODE 



TOTAL 



REA SUS 



HERD NUMBER 



HERD OWNER S COMPLETE ADDRESS 



CERTIFICATION FOR PAYMENT 



1 — 1 Stale/Federal i — i Owners 

 1 — 1 Expense 1 — ' Expense 



DATE LISTED 



LESION TEST 



D-B 



U 



1 certity 



That this test was made and read by me on each of the cattle identified Delow 



on the dates and with Ihe results as entered m appropriate spaces 



COUNTY 



! TOWNSHIP OR DBTRICT 



SEC. 1 FARM NO 



1 



That when payment is claimed at program expense in accordance with 

 agreement number below, no payment has been or will be received frorr' any 

 other source 



REASON FOR TEST 



COUPLETEMESDIESTOf 

 ALL EUCIPI P ANIUAU^ 



SUMMARY 



PRACTITIONER S SIGNATURE 



TELEPHONE NO 



AREA 1 





RETEST 



6 





~ YES ~ NO - 





NEG- 

 ATIVE 











PRACTITIONER S NAME tPissse pnnri 



AGREE CODE 



HERO iREi ^ 





TRACING 

 REG. KILL 



7 







KIND OF HERD 

 1 I DEER 1 1 ELK 





ACCREPr 



SUS- 

 PECT 









INJECTION 



DATE 



HOUR 



MILK 3 

 ORDINANCE 





TRACING 

 REACTORS 



B 





i '■ CATTLE 1 BISON 



1 — 1 



^ OTHER 







REAC- 

 TOR 







4 

 SALE-SHOW 





TRACING 

 EXPOSED 



9 



1 



METHOD OF TEST 



n CAUDAL FOLD r-^ SNG CERVICAL 

 1— 1 (CFT) U (CST) (Cervid) 



OBSERVATION 



DATE 



HOUR 





TOTAL 









REACTOPS TAGCEO AND BRAMDED 





5 





OTHER 



10 





—1 CERVICAL 

 1 — ■ (CT) (Bovine) 





AGREE CODE 





'—' OTHER 









^ lOEHTincATlCW 

 1 NUMSEP 





1 



PESULTS 



PEACTOP 

 TAG NO 



^ IDENTIFICATION 

 I NUIKBER 



AGE 



BREED 



SEX 



RESULTS 



REACTOR 







SIZE 



NRS 



SIZE 



NRS 



TAG NO 





1 

















16 

















2 

















17 

















3 

















IS 



















4 

















19 



















5 

















20 

















6 

















21 

















7 

















22 

















e 

















23 

















9 

















24 

















10 

















25 

















11 

















26 

















12 

















27 

















13 

















28 















14 

















29 

















IS 

















30 















RT - Retag 



NA - Natural Addition 



PA - Purchased Addition 



N - Negative 

 S - Suspea 

 R - Reactor 



; hereby acknowledge receiving a copy ot this record which t 

 have examined and find correct 



OWNER S SIGNATURE 



THIS ALTTHOHIZATION TO 

 TEST EXPIRES: 



VS FORM 6-22 (FEB 99) 



Previous editions are obsolete 



PART 1 - OFFICE 



16-17 



