VS 10-4A Continuation Sheet for Specimen Submission

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, 0212, and 0324. The time required to complete this information collection is estimated to average .5 hours per response for 0579-0090, 1 hour per response for 0579-0101, and .25 hours per response for 0579-0212 and 0324, 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, 0579-0212, and 0579-0324
UNITED STATES DEPARTMENT OF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECTION SERVICE VETERINARY SERVICES CONTINUATION SHEET FOR SPECIMEN SUBMISSION			INSTRUCTIONS: Use this form only as a continuation of information on VS Form 10-4 see “Instructions for completing VS Form 10-4”.	PAGE: OF
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					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. Please limit to <250 specimens per VS Form 10-4.