Accofding to the Papetwori^ Reduction Act of 1995, no pereons are required to respond to a collectJon of information unless it displays a valid 0MB control nunnber Tbe valid 0MB 

 control numtjer for ttiis information collection is 0579-0127 The time required to complete this infomiation coJiecton is estimated to average .416 hours per response, including the 

 time for reviewing mstnjctjons, search existing data sources, gathenng and maintaining tfie data needed, and completing and reviewing the collection of information. 



USE TYPEWRITER OR PRINT CLEARLY 



FORM APPROVED • OMB NO. 0579-0127 



U.S. DEPARTMENT OF AGRICULTURE 

 ANIMAL AND PLANT HEALTH INSPECTION SERVICE 



EQUINE INFECTIOUS ANEMIA SUPPLEMENTAL INVESTIGATION 



(VS Memorandum 555 8) 



1. CASE ID 



2. LAB ACCESSION NO. 



3. INVESTIGATOR'S NAME (last, firsf. & middle initial) 



4. INVESTIGATOR'S AFFIUATION 



5. INVESTIGATION DATE 



Area Code & Telephone No. 





6. OWNER'S LOCATION 



7. NAME OF CONTACT PERSON (e.g. stable manager) 



Name 



Contact Name 



Street Address 



Street Address 



City 



City 



State 



State 



Zip Code 



Zip Code 



County 



County 



Area Code & Telephone No. 



Area Code & Telephone No. 



8. FARM OR RANCH OPERATION 



Type of Operation 



Specialty Acreage 



No. of Buildings Are There Other Adjacent Equine Operations 



r^ Yes p^ No If Yes, Give Number 



9. ANIMAL POPULATIONS 



No. of Equlds on Premises 



No. of Equlds having Possible Contact with Positive 

 Case Animals 



Other Uvestock Animals on Premises (list total numt>er by species) 

 Cattle^ 



Pigs 



Sheep 



Goats 



Other 



No. of Equlds Sharing Pasture with Case Animal 



Are Wild Equlds Present within 200 yards of this Premises 



I Yes I I No ifYes, Give Number 





10. HISTORY OF CASE ANIMAL 





Name 



Color 



Registration Number 



Breed 



Age (in months only) 



Sex (male, female, gelding, neuter) 



Primary Use of animal (Please check one box.) 



I" n Pleasure I ^ Show ; Work 



Other (Please Describe) 



11. SOURCE OF ANIMAL 



Was the Animal Bom on Owner's Premises 



' I Yes I I No If No, Please Give Location Where Bom 



Was the Animal Purchased 



Q] Yes j"" ; No 



If Yes. Please Give the Seller's Name and the Address 

 Where Animal Resided Prior to Purchase by Current Owner 



How Long Has the Case Animal Been at the Current SKe Prior to the EIA PosiUve Test (in months only) 



12. ANIMAL HOUSING 



Proportion of Time Case Animal Spent 



In stable (%) [""] □ ** 



On pasture (%) jo j I 25 



Size of Pasture Area Where Case 

 Animal was Kept (acres) 



Maintenance 



Q] Poor Qj Good 



I I Moderate 



Is there Water Runoff In 

 Vicinity of Stable 



[J 



Yes 



r'! No 



None j ^1 Well ! 1 Imgation 



F'j Lake M Stream ni Other 



n Stock Pond [^ | Natural Pond 



13. TRAVEL HISTORY 



Dates of Off-premises Gathering of 

 Equlds Attended by Case Animal within 

 Six Months of the EIA Positive Test 



' Types of Off-premises Gatherings of Equlds 

 Attended by the Case Animal within Six 

 Months of the EIA Positive Test 



Was the Case Animal within 200 Yards of Another Animal Known to be 

 ElA-poslthre within Six Months of the EIA Positive Test 



I I I Yes O ^° I i No'C®'^'" 



IF YES, IDENTIFY PREMISE(S) AND ALL EXPOSED EQUIDS IN 

 COMMENTS SECTION, PAGE 3. 



VS FORM 10-12 

 (DEC. 2003) 



Page 1 of 3 



16-29 



