Form 10-11 Equine Infectious Anemia Laboratory Test

See reverse for more OMB information.

FORM APPROVED - OMB NUMBER 0579 - 0127
SERIAL NO.

U.S. DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE

EQUINE INFECTIOUS ANEMIA LABORATORY TEST

1. ACCESSION NUMBER

2. DATE BLOOD
DRAWN

K

(VS Memorandum 555.16)

Forms Without Adequate Descriptions Of The Horse and Complete Addresses Including Zip Codes, Counties, and Telephone
Numbers Will Not Be Processed.
3. REASON FOR TESTING

Market

Change of Ownership

4. GEOGRAPHIC INFORMATION
SYSTEMS (GIS)

Show

First Test

Retest

Export

7. NAME AND ADDRESS OR STABLE/MARKET (Please print or type)

6. TEST TYPE

5. VETERINARY LICENSE
OR ACCREDITATION NO.

ELISA

LAT:
LONG:

Zip Code

AGID

County

Tel No.

8. NAME AND ADDRESS OF OWNER (Please print or type)

9. NAME AND ADDRESS OF VETERINARIAN (Please print or type)

Zip Code

Zip Code

County

Tel No.

County

Tel No.

CERTIFICATION OF FEDERALLY ACCREDITED VETERINARIAN
I certify the specimen submitted with this form was drawn by me from the horse described below on the date indicated above.
11. TYPE OR PRINT SIGNATURE NAME

10. SIGNATURE OF FEDERALLY ACCREDITED VETERINARIAN

12. SIGNATURE DATE

CERTIFICATION OF OWNER OR OWNER'S AGENT
I certify that I have examined this form and, to the best of my knowledge and belief, this form is true, correct and complete.
13. SIGNATURE OF OWNER OR OWNER'S AGENT

16 .
Tube
No.

Official

18.

Tag

Tattoo/Brand

14. TYPE OR PRINT SIGNATURE NAME

19.
Name of Horse

20.
Color

15. SIGNATURE DATE

22.
Electronic
I.D. No.

21.
Breed

23.
Age or
DOB

24.
Sex

M - Male
F - Female
G - Gelding
N - Neuter

SHOW ALL SIGNIFICANT MARKINGS, WHORLS, BRANDS, AND SCARS

5

5
4

4
3

3

3

3
1

2

2

1

2

2
1 - Coronet, 2 - Pastern, 3 - Fetlock, 4 - Knee, 5 - Hock

NARRATIVE DESCRIPTION AND REMARKS
25. HEAD

26. OTHER MARKS AND BRANDS

27. LEFT FORELIMB

28. RIGHT FORELIMB

29. LEFT HINDLIMB

30. RIGHT HINDLIMB

FOR LABORATORY USE ONLY
31. LABORATORY NAME/CITY/STATE

32. DATE RECEIVED

33. DATE REPORTED OUT

34. TEST RESULTS

Negative
36. SIGNATURE OF TECHNICIAN

Positive

AGID

35. REMARKS

Falsification of this form or knowingly using a falsified form is a criminal offense and may result in a fine of not more than $10,000 or
imprisonment for not more than 5 years or both (U.S.C. Section 1001).
VS FORM 10-11 (MAY 2003)

ELISA

COPY DESIGNATIONS

PART. 1 - OWNER
PART. 2 - LABORATORY OFFICE
PART. 3 - VETERINARIAN/SUBMITTER
PART. 4 - AREA VETERINARIAN-IN-CHARGE
PART. 5 - STATE

EQUINE INFECTIOUS ANEMIA LABORATORY TEST

VS FORM 10-11
(JUN 2003)

USDA - APHIS

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0579-0127. The time required to complete this information
collection is estimated to average .083 hours per response, including the time for reviewing instructions, search existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information.

VS FORM 10-11
REVERSE

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