VS 5-19D Scrapie Epidemiology Report

According to the Paperwork Reduction Act of 1995, no persons are required to re spond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0579- 0101. The time required to complete this information collection is estimated t o
average 5.5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information.

FORM APPROVED
OMB NO.
0579-0101

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES
SCRAPIE EPIDEMIOLOGY REPORT
Flock ID

Owner's Name and Address

Flock Location, if Different

Telephone

Inspector's Name

Inspection Date

Type of Flock
___________
___________
___________
___________
___________

Quarantine Number

Inspector's ID

County

Latitude

Longitude

SHEEP

GOATS

INVENTORY
Adult Males
Adult Females
Yearling Males
Yearling Females
Female Lambs/Kids
Male Lambs/Kids
Castrated Males
Total

Purebred
Commercial Breeder
Club Lamb Producer
Feeder
Other_____________________________________________

Veterinary Practitioner's Name

Predominant Breed

1. Number of sheep or goats currently in the flock with clinical signs suggestive of scrapie:___________________________
2. Clinical signs suggestive of scrapie observed by the producer or inspector (including index case)
[ ] No clinical Signs of Scrapie
[ ] Excitable
[ ] Incoordination
[ ] Abortions
[ ] Weight Loss
[ ] Convulsions
[ ] Itching/Rubbing
[ ] Skin Abrasions from Rubbing
[ ] Involuntary Muscle Tremors
[ ] Nibbling and Licking Movements
3. What is the approximate date when the first clinical signs suggestive of sc rapie were seen:______________________
4. Total number of sheep or goats that have shown clinical signs suggestive of scrapie in the past 5 years:_________________
5. Number of adult deaths from all causes over the last year:___________________
6. Total number of sheep or goats that have shown clinical signs suggestive of scrapie in the past 5 years:____________________________
7. Percentage of Rams Genotyped:__________________
8. Percentage of Ewes Genotyped:__________________
9. Written or computer records kept
YES
YES
YES
YES
YES
YES

NO
NO
NO
NO
NO
NO

Identification
Sex
Breed
Date of Birth
Animal Sire and Dam information
Sales Information - ID, buyer, date purchased

10. Description of lambing facilities:
11. How often is the lambing area cleaned and disinfected:____________________ _______________________________________________
12. Are separate contemporary lambing groups used: YES NO
13. Method of disposal of placentas:__________________________________________ __________________________________________
14. Method of disposal of dead sheep:_________________________________________ ________________________________________

VS FORM 5-19D
(NOV 2005)

EPIDEMIOLOGY

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15. Complete the following information on each laboratory confirmed case and c linically suspicious case currently in the flock. Complete as much information as possible on any
clinically suspicious cases in the flock over the last 5 years.
ID

SOURCE

SEX

BREED

PURCHASE DATE

BIRTH DATE

DATE OF CLINICAL SIGNS

SELLER'S NAME AND ADDRESS

LAB CONFIRMED
YES
NO

DESCRIBE DOCUMENTATION OF
PURCHASE

PURCHASED
BORN ON FARM
COMMENTS ON HISTORY

ID

If lab confirmed Scrapie case - list the status of all offspring
STATUS
ID
YEAR BORN

YEAR BORN

ID

SOURCE

SEX

BREED

PURCHASE DATE

BIRTH DATE

STATUS

DATE CLINICAL SIGNS

SELLER'S NAME AND ADDRESS

LAB CONFIRMED
YES
NO

DESCRIBE DOCUMENTATION OF
PURCHASE

PURCHASED
BORN ON FARM
COMMENTS ON HISTORY

ID

VS FORM 5-19D
(NOV 2005)

YEAR BORN

If lab confirmed Scrapie case - list the status of all offspring
STATUS
ID
YEAR BORN

EPIDEMIOLOGY

STATUS

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9. Conclusions on source of infection and general plan of action.

Investigator's Name

VS 5-19D
(NOV 2005)

Title

EPIDEMIOLOGY

Date

PAGE 8 of 8