VS 5-29 Cooperative State - Scrapie Control Program

According
to thetoPaperwork
Reduction
Act ofAct
1995,
no persons
are required
to respond
to a collection
of information
unless
it displays
a valid
OMBOMB
control
number.
number
for thisfor this
According
the Paperwork
Reduction
of 1995,
no persons
are required
to re spond
to a collection
of information
unless
it displays
a valid
control
numThe
ber.valid
TheOMB
valid control
OMB control
number
information
collection
is 0579-0101.
TheThe
timetime
required
to complete
thisthis
information
collection
is estimated
to average
2 hours
per response,
including
the time
instructions,
searching
existing
data
information
collection
is 0579-0101.
required
to complete
inform ation
collection
is estimated
to average
.3 hours
per response,
including
the tfor
imereviewing
for reviewing
instructions,
search
existing
data
sources, gathering and maintaining the data needed,
and completing
reviewing the
collection
of information.
sources,
gathering and maintaining
the
data needed,
and completing and reviewin g the collection of information.

STATE

FORM APPROVEDOMB NO. 0579-0101

ALL INCOMPLETE RECORDS WILL BE RETURNED FOR COMPLETION

A

COOPERATIVE STATE - FEDERAL SCRAPIE CONTROL PROGRAM

REFERRAL NO.

SCRAPIE TEST RECORD
COUNTY OF OWNER

FLOCK OWNER'S NAME - LAST

FLOCK ID

FLOCK OWNER'S COMPLETE ADDRESS

COUNTY OF FLOCK

2

3
HIGH RISK
TRACE TO
FLOCK
4
OWNER'S
REQUEST

NO

PERSON ID (VETERINARIAN/SNGD)

TOTAL # OF
SAMPLES

CERTIFICATION FOR PAYMENT
Owner's
Cooperative
State/Federal
Expense
Agreement
Expense
I certify:
That this test was made by me on the animals identified below on the dates as
entered in appropriate spaces.
That when payment is claimed at program expense in accordance with
agreement number below, no payment has been or will be received from any
other source.
VETERINARIAN'S SIGNATURE

VETERINARIAN'S NAME (Please print)

7
INFECTED
OR SOURCE
RSSS POS.

TELEPHONE NO

MIXED
LAB TURN AROUND TIME
5 DAY TURNAROUND

MISSING 9
EXPOSED
EWE (ME)

171 CODON ONLY

OTHER

VETERINARIAN'S ADDRESS

OTHER

GOAT

8
INFECTED
OR SOURCE
(NOT RSSS)

10

COLLECTION DATE

KIND OF FLOCK

SHEEP

10 DAY TURNAROUND
FAX NO. OR E-MAIL ADDRESS

AGREEMENT NO.

TEST TYPE
FLOCK STATUS

171/136 CODON

136 CODON ONLY

171/136/154 CODON

THIRD EYELID (TE)

OTHER

SFCP

EXPOSED

INFECTED

NONE

SOURCE

INVEST

OTHER

Official ID Number

Other ID Numbers

Designation
(pos, sus,
exp, me, n/a)

Age

Breed
Sex
(if unkn,
(m,f,cm)
face
color)

3rd Eyelid Info

L

R

Seen
Unseen

L

R

Seen
Unseen

L

R

Seen
Unseen

L

R

Seen
Unseen

L

R

Seen
Unseen

L

R

Seen
Unseen

L

R

Seen
Unseen

L

R

Seen
Unseen

L

R

Seen
Unseen

L

R

Seen
Unseen

Circle if the 3rd eyelid tissue came from the Left or Right eye
Circle if the lymphoid tissue was Seen or Unseen

Sample numbers on specimens must be the same as listed on this form.

DSE Name:

YES

NO. OF ANIMALS IN FLOCK

Specimen #

NOTE:

FARM NO.

COMPLETE FLOCK TEST OF ALL ELIGIBLE ANIMALS:

RETEST

5
IMPORTED

SEC.

PREVIOUS TEST DATE

6

1

FLOCK (RE)
CERTIFICATION

MI

FLOCK OWNER'S TELEPHONE NUMBER

REASON FOR TEST
SURVEILLANCE

FIRST

Remarks:

Address:

Phone Number:

DATE

OWNER'S SIGNATURE:

Fax Number:
E-Mail:

VS FORM 5-29
(SEP 2007)

I hereby acknowledge receiving a copy of this record which I have examined and find correct.

USE TYPEWRITER OR PRINT CLEARLY - PRESS HARD - YOU ARE MAKING 5 COPIES

COPY DESIGNATION
RED INK - CENTER OF BOTTOM OF PAGE
PART 1 - Area Office
PART 2 - Laboratory
PART 3 - DSE
PART 4 - VMO
PART 5 - Owner