Vs 10-4a Specimen Submission Continuation Sheet

Specimen Submission

10-4A

SPECIMEN SUBMISSION - BUSINESS

OMB: 0579-0090

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According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not 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 0579-0090, 0101, and 0212. The time required to complete this information collection is estimated to average .0333 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 sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

OMB Approved

0579-0090, 0579-0101, and 0579-0212

UNITED STATES DEPARTMENT OF AGRICULTURE

ANIMAL AND PLANT HEALTH INSPECTION SERVICE

VETERINARY SERVICES

CONTINUATION SHEET FOR

SPECIMEN SUBMISSION

PAGE:


OF

INSTRUCTIONS: Use this form only as a continuation of information on VS Form 10-4 see “Instructions for completing VS Form 10-4”.

3. NAME OF OWNER/BROKER Check if wildlife (no owner)



15. REFERRAL NUMBER


OWNER CITY

OWNER STATE/COUNTRY



21. IDENTIFICATION (See instructions)

IDENTIFICATION

Sample ID

Animal ID

Breed

Age

Sex

Sample ID

Animal ID

Breed

Age

Sex

















































































































































































































































VS FORM 10-4A

AUG 2009




INSTRUCTIONS FOR VS FORM 10-4A


PAGE

Enter the number for this page out of the total number of pages submitted (e.g., 2 of 3).


NAME OF OWNER/BROKER

Enter the complete name of the animal owner from VS Form 10-4, block 3.


REFERRAL NUMBER

Enter the referral number from VS Form 10-4, block 15.


IDENTIFICATION

Continue the specimen numbering sequence started on VS 10-4, block 21. Enter the National Animal ID, breed, age, and sex of each animal sampled. If more than 48 specimens are submitted, use additional VS Form 10-4A as required.

File Typeapplication/msword
File TitleAccording to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond
AuthorKhbrown
Last Modified ByKhbrown
File Modified2009-09-14
File Created2009-08-14

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