VS Form 10-4: Specimen Submission 



If you have only one form to send, fill in 1 of 1. If 

 you used a continuation form, fill in the appropriate 

 numbers, e.g., 1 of 2 or 3 of 6. 



NAME OF SUBMITTER, MAILING ADDRESS 



Enter your name, address, and telephone number. 



NAME OF OWNER/BROKER 



Self-explanatory. 



LOCATION OF ANIMALS 



This information may be different from the owner's 

 address and can become very important in the event 

 of a traceback. 



HERD/FLOCK SIZE 



Fill in, if applicable. 



NO. IN HERD/FLOCK AFFECTED 



Enter the number of sick animals. 



NO. IN HERD/FLOCK DEAD 



Enter the number of dead animals. 



EXAMINATIONS REQUESTED 



List all tests or procedures you want conducted. May 

 be an "if, then" statement. For example, "If Salmonella 

 is isolated, perform serotype testing." 



COLLECTED BY 



Enter the name of the person who collected the 

 samples. This person may not be you, the submitter. 



DATE COLLECTED 



Enter the date that sample was collected. 



AUTHORIZED BY 



This entry will usually be the Area Veterinarian-in- 

 Charge in your State. 



PURPOSE OF SUBMISSION 



Mark the appropriate box. Explanations of choices are 

 on the reverse side of part 5 (last sheet of the form). 



COUNTRY OF ORIGIN 



If test is for import or export, complete this box; if not, 

 leave blank. 



REFERRAL NUMBER 



The referral number will be provided to you by the Area 

 Veterinarian-in-Charge in your State. All submissions to 

 NVSL must be cleared through the Veterinary Services 

 area office and be assigned a referral number. 



PRESERVATION 



Mark the appropriate box. 



SPECIMENS SUBMITTED 



Mark the appropriate box. 



TOTAL NUMBER OF SPECIMENS SUBMITTED 



Self-explanatory. 



SPECIES OR SOURCE 



M.uk the appropriate box; mark one box onl\. It \ou 

 have samples from multiple species, use one form 

 per species. 



NUMBER OF ANIMALS SAMPLED 



Data in this bl(K"k and in the "Total Number of 

 Specimens Submitted" block will not be the same if 

 there are multiple specimens per animal. Enter the 

 correct number in each block. 



IDENTIFICATION 



An explanation and example tor this block is on the 

 reverse side of part 5 (last sheet of the form). 



ADDITIONAL DATA 



List other pertinent inlorm.itidn. 



SIGNATURE OF SUBMITTER AND DATE 



Si"n and date the form. 



16-22 



