See reverse side for OMB information. 



FORM APPROVED: OMB NUMBER 0579-009C 



US DEPARTMENT OF AGRICULTURE 



ANIMAL ANO PLANT HEALTH INSPECTION SERVICE 



NATK3NAL VETERINARY SERVICES LABORATORIES 



PC BOX 844 1800 DAYTON AVENUE 



(5151239-82121 



AMES KDWA 50010 



SPECIMEN SUBMISSION 



INSTRUCTIONS: Use a separate request for each 

 species and each owner/broker See reverse for 

 definitions (Item 12) and instructions for Identification 

 (Item 20). 



PAGE 



OF 



1 NAME OF SUBMITTER 



2. NAME OF OWNER 



MAILING ADDRESS (Street, City, State, and Zip Code) 



CITY 



STATE 





3. LOCATION OF ANIMALS 





COUNTY 



STATE 



Phone No. FAX No. 







4. PAYMENT METHOD fX" applicable item and provide information) 

 Q USER FEE ACCOUNT NO.: 



Q MCA/ISANO.: 



EXP. 

 DATE: 



I I CHECK/MONEY ORDER ENCLOSED (Made payable to USDA" in U S Dollars) 



5 HERD/FLOCK SIZE 



8 EXAMINATIONS REQUESTED 



9. COLLECTED BY 



6. NO IN HERD/FLOCK AFFECTED 





10. DATE COLLECTED 



7 NO IN HERD/FLOCK DEAD 





11. AUTHORIZED BY 



12 PURPOSE OF SUBMISSION ("X" one) (See reverse side of Pan 3 (or definitions) 



1 1 General Diagnostic f~~\ Surveillance FH Import i — i Interstate 

 I 1 FAD/EP Diagnostic |^ Developmental Research [^ Export — Movement 

 1 1 NVSL Intralab Diagnostic Q Reagent Evaluation Q TB 



13. COUNTRY OF ORIGIN 



14. REFERRAL NUMBER 



IS. PRESERVATION fX' applicable item(s) 



I I None 1^ Ice Pack [^ Dry Ice 



I I Formalin FH Borax FH Alcohol Fj Other (specify) 



16 SPECIMENS SUBMITTED ('X' applicable item(s)) 



1 Blood Q Feces Q Parasite Q Serum Q Tissue Q Whole Bird Q Other (specify) 

 1 1 Culture Q Feed Q Plant [^ Soil Q Urine Q Fetus 

 n Extract f~| Milk | | Semen | | Swab | | Water 



17. TOTAL NUMBER OF SPECIMENS 

 SUBMITTED 



18. SPECIES OR SOURCE ("X" one) 



1 1 Cattle [^ Goat |^ Environment |^ Chicken |^ Bison [^ Deer [^ Other (specify) 

 1 1 Swine Q Horse Q Reagent [^ Turkey Q Dog Q Elk Q 

 n Sheep n Donkey Q □ Pet Bird n Cat n f^ish n 



19. NUMBER OF ANIMALS SAMPLED 



20. IDENTIFICATION (See reverse side of Part 5) 



IDENTIFICATION (See reverse side of Part 5) 



Sample ID 



Animal ID/Breed 



Age 



Sex 



Sample ID 



Animal ID/Breed 



Age 



Sex 



















































































21. ADDITIONAL DATA (History, clinical signs, post mortem findings, remarks, tentative diagnosis, etc. Use 

 additional sheets if necessary ) 





22. SIGNATURE OF SUBMITTER AND DATE 





NVSL USE ONLY 





CONDITION 



PRIORITY 



DISTRIBUTION 



RECEIVED BY 



NVSL ACCESSION 



NO 





VS FORM 10-4 (JULY 97) 



16-23 



