14. PREMISES INFECTION HISTORY 



Date of the FIret Test Yielding a 

 PocKlve Response 



Date of the Last Negative 

 ElATest 



Are Other Animals wtth EIA Positive Tests Are Other Animals with EIA Positive Tests Present 



on Neighboring Premises 



Present on the Premises 



□ Yes □ NO 



c 



Yes 



D 



No 



List Other Infections Diagnosed on Premises for All Animals within the Past Three Years 



15. VACCINATION HISTORY 



List Vaccines and Dates Administered List Vaccines and Dates Administered to Equlds on Premises Other Who Administered ttie Vaccines (check all that apply) 



to EIA Test-Positive Animal 



than Those Given to the EIA Test Positive Aninial 



I I Owner 



I i Vetennanan 



Neightxjr 

 Other 



'' Farm Worlter 



16. INJECTABLE MEDICATION HISTORY 



List InJecUble Medication and Dates Admlrilstered to EIA Test Positive Animal I Who Injected the Medication 



Owner Farmworker ' I Neighbor | | Veterinarian I I Ottw 



17. VETERINARY MEDICAL ACTIVITIES 

 Other than EIA Testing, were the Services of a Veterinarian Used within the Past Six Months 

 I Yes I i No I' Yes. Please Indicate the Dates and the Nature of the Serinces Performed 



Were Any of These Services Performed on the ElA-posltlve Animal 



Yes 



No 



If yes, specify 



18. FLY CONTROL 



Have Fly Control Measures Been Applied within the Past Six Months 

 If yes, Were the Treatments 



Repellents applied to animals I j Yes I I No 



Insectiades applied generally to the pasture areas \ Yes ' ' No 



G^«» D 



No 



Repellents applied on or near animal housing I I Yes I 1 No 



Insecticides applied in or near animal housing areas [~1 Yes ' 1 No 



19. ENVIRONMENT SURROUNDING PREMISES 

 Describe the Area Surrounding the Premises in Ecological terms 

 Marsh [Shrubiand 



Swamp 



Upland Deciduous Forest 



Grassland 



Desert 



Flood Plain Deciduous Forest 



Coniferous Forest 



OttMf 



20 SKETCH OF THE PREMISES RELATIVE TO ROADS, WATER SOURCES. AND LANDMARKS 



Site Sketch 



Latitude (ddmmss) 



West 



North 



East 



South 



(Show in sketch with an X mark wftene tfie coortinates were obtained) 



; Longitude fddmmss; Datutrt Used, If Known 



This Location Is 



Front gate 



Stable 



Pasture 



[ ] Other (please identity) 



VS FORM 10-12 



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