VS Form 10-11: Equine Infectious Anemia Laboratory Test 



ACCESSION NUMBER 



The accession number is assigned by the laboratory. 

 Leave blank. 



DATE BLOOD DRAWN 



Self-explanatory. If there are any time constraints 

 on the test (as with exports), they are from the date 

 that the sample is drawn rather than from the date 

 the sample is submitted or the date the test result 

 is reported. 



REASON FOR TESTING 



Mark the appropriate box. 



GEOGRAPHIC INFORMATION SYSTEMS (GIS) 



Enter longitude and latitude if applicable. 



VETERINARY LICENSE OR ACCREDITATION NO. 



Self-explanatory. 



TEST TYPE .\Kirk the appropriate box. 



NAME AND ADDRESS OF STABLE/MARKET 



Enter the name, address, and telephone number of 

 where the horse is stabled or the auction market 

 is located. 



NAME AND ADDRESS OF OWNER 



Enter the name, complete mailing address, and 

 telephone number of the owner. 



NAME AND ADDRESS OF VETERINARIAN 



Enter your name, complete mailing; address, and 

 telephone number. 



CERTIFICATION OF FEDERALLY ACCREDITED 

 VETERINARIAN [blocks 10-12] 



Self-explanatory. 



CERTIFICATION OF OWNER OR OWNER'S AGENT 

 [blocks 13-15] 



Self-explanatory. This section provides the veterinarian 

 legal protection when misrepresentation of a horse is 

 suspected; this is optional and is not required to com- 

 plete the form. 



DATA IDENTIFYING THE ANIMAL BEING TESTED 

 [blocks 16-24] 



Fill out as completely as possible. This area can cause 



the greatest number of problems, especialK' during 



interstate or international movement. The description 

 MUST match the horse exactly; therefore, be precise 

 when indicating the markings. 



TUBE NUMBER l- nter tube number if applicable. 



OFFICIAL TAG NUMBER 



Enter tag number if applicable. 



TATTOO/BRAND 



Enter tattoo or brand if applicable. 



NAME OF HORSE 



Enter the horse's complete name. 



COLOR Inter the color of the horse. 

 BREED 1 nter the breed o{ the horse. 



ELECTRONIC I.D. NUMBER 



Enter the animal's electronic I.D. number if applicable. 



AGE OR DOB 



Enter the horse's age in years or exact date of birth 

 if available. 



SEX 



To indicate the sex, use the codes listed on the form. 



SHOW ALL SIGNIFICANT MARKINGS, WHORLS, 

 BRANDS, AND SCARS 



fill in the silhouettes as needed to accurately describe 

 the individual animal. 



Narrative Description and Remarks 

 [blocks 25-30] 



Fill out as completely and precisely as possible. On the 

 reverse side of the top [white] sheet in the carbon pack, 

 you will find narrative descriptions and suggested lan- 

 guage for these blocks. 



FOR LABORATORY USE ONLY [blocks 31-35] 



Leave blank. 



16-26 



