VS 10-4 Specimen Submission

See reverse side for OMB information.

FORM APPROVED: OMB NUMBERS 0579-0090, 0101, and 0212

U.S. DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
NATIONAL VETERINARY SERVICES LABORATORIES
P.O. BOX 844, 1800 DAYTON AVENUE, AMES, IA 50010
(515) 239-8212

PAGE

INSTRUCTIONS: Use a separate request for each
species and each owner/broker. See reverse for
definitions (Item 12) and instructions for Identification
(Item 20).

SPECIMEN SUBMISSION
1. NAME OF SUBMITTER

2. NAME OF OWNER

MAILING ADDRESS (Street, City, State, and Zip Code)

CITY

OF

STATE
3. LOCATION OF ANIMALS

COUNTY
Phone No.

STATE

FAX No.

4. PAYMENT METHOD ("X" applicable item and provide information)

EXP.
DATE:

MC/VISA NO.:

USER FEE ACCOUNT NO.:
CHECK/MONEY ORDER ENCLOSED (Made payable to "USDA" in U.S. Dollars)
8. EXAMINATIONS REQUESTED

5. HERD/FLOCK SIZE

9. COLLECTED BY

6. NO. IN HERD/FLOCK AFFECTED

10. DATE COLLECTED

7. NO IN HERD/FLOCK DEAD

11. AUTHORIZED BY

12. PURPOSE OF SUBMISSION ("X" one) (See reverse for definitions)
General Diagnostic
Surveillance

13. COUNTRY OF ORIGIN
Import

Interstate
Movement

FAD/EP Diagnostic

Developmental Research

Export

NVSL Intralab Diagnostic

Reagent Evaluation

TB

Dry Ice

Formalin

Borax

Alcohol

Other (specify)

Serum

Tissue

Whole Bird

Other (specify)

Fetus

14. REFERRAL NUMBER

15. PRESERVATION ("X" applicable item(s)
None

Ice Pack

16. SPECIMENS SUBMITTED ("X" applicable item(s))
Blood
Feces
Parasite
Culture

Feed

Plant

Soil

Urine

Extract

Milk

Semen

Swab

Water

Environment

Chicken

Bison

Deer

Reagent

Turkey

Dog

Elk

Pet Bird

Cat

Fish

18. SPECIES OR SOURCE ("X" one)
Cattle
Goat
Swine

Horse

Sheep

Donkey

19. NUMBER OF ANIMALS SAMPLED

20. IDENTIFICATION (See reverse)
Sample ID

17. TOTAL NUMBER OF SPECIMENS
SUBMITTED

Animal ID/Breed

Other (specify)

IDENTIFICATION (See reverse)
Age

Sex

Sample ID

Animal ID/Breed

Age

21. ADDITIONAL DATA (History, clinical signs, post mortem findings, remarks, tentative diagnosis, etc. Use
additional sheets if necessary.)

22. SIGNATURE OF SUBMITTER AND DATE

NVSL USE ONLY
CONDITION

PRIORITY

DISTRIBUTION

RECEIVED BY

NVSL ACCESSION NUMBER
VS FORM 10-4 (APR 08)

Sex

Item 12 - Definitions of Diagnostic Case Categories
General Diagnostic Case - A case in which the tests conducted are for the purpose of diagnosing or confirming a domestic disease, and/or the analysis
of environmental products that may be contributing to an existing disease condition.
FAD/EP Diagnostic Case - A case in which the tests conducted are for the purpose of diagnosing or confirming a foreign disease, or for the eradication
of a foreign disease that has gained entrance into the U.S.
NVSL Intralab Diagnostic Case - A case in which the tests conducted are for the purpose of diagnosing or confirming a disease condition, analyzing
environmental products that may be contributing to a disease condition or for analyzing chemical products for another laboratory of NVSL.
Surveillance/Monitor Case - A case in which the tests conducted are for the purpose of monitoring for a specific disease, for a specific insect or insect
vector, or for analyzing specific products that are used in treating animals or poultry or for decontamination of animal or poultry facilities.
Developmental/Research Case - A case in which the tests conducted are for the purpose of supporting a developmental or research project conducted
by another laboratory of NVSL, by staff or field personnel of VS, or by other laboratories, institutions, or agencies.
Reagent Evaluation Case - A case in which the tests conducted are for the purpose of evaluating a reagent produced by another laboratory of NVSL or
by other laboratories, institutions, or agencies.
Import Case - A case which the tests conducted are for the purpose of qualifying animals or poultry, including wild animals and birds, or animal or
poultry products for importation into the U.S.
Export Case - A case which the tests conducted are for the purpose of qualifying animals or poultry, including wild animals and birds, or animal and
poultry products for exportation to a foreign country.
TB - A case with a specific request for diagnosis of TB.

Item 20 - Identification
Identify Samples with Consecutive Numbers - Record animal identification (number or name) adjacent to appropriate sample number. Laboratory
results will be reported by sample identification number. Indicate approximate age in years(y), months(m), weeks(w), or days(d), and indicate sex of
each animal. See sample below. When more than 10 samples, use VS Form 10-4A.

IDENTIFICATION

AGE

SEX

12ABC0000

3y

2

12ABC0001

3

Sample

Animal

1

IDENTIFICATION

AGE

SEX

12ABC0005

10d

F

7

12ABC0006

10m

F

F

8

12ABC0007

8m

M

6m

F

9

12ABC0008

21/2y

F

3w

M

10

12ABC0009

15m

M

Sample

Animal

F

6

2y

M

ABC002

1y

4

ABC0003

5

12ABC0004

Send a copy of the VS 10-4 to the Veterinarian-in-Charge (in submitter's State).
Retain a copy for your records.

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 numbers for this information collection are 0579-0090, 0101, and 0212. The time required to complete these
information collections is estimated to average . 5 hours per response for 0579-0090, 1 hour per response for 0579-0101, and .333 hours per response for
0579-0212, including the time for reviewing instructions, searching existing data resources, gathering and maintaining the data needed, and completing
and reviewing the collection of information.

VS 10-4 (Reverse)