Form PPQ-305 Insect Collection Worksheet for Genotype Analysis

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 0579-0104. The time
required to complete this information collection is estimated to average .17 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.
1. INSECT NAME
UNITED STATES DEPARTMENT OF AGRICULTURE

OMB APPROVED
0579-0104
EXP: XX/XXXX

ANIMAL AND PLANT HEALTH INSPECTION SERVICE
PLANT PROTECTION AND QUARANTINE

INSECT COLLECTION WORKSHEET FOR
GENEOTYPE ANALYSIS
COMPLETE FOR EACH TRAP CONTAINING SPECIMENS
2. SUBMITTER’S NAME

3. SUBMITTER’S ADDRESS (Include ZIP Code)

4. SUBMITTER’S EMAIL ADDRESS

5. SUBMITTING AGENCY

STATE

TELEPHONE NUMBER

OTHER
ORGANIZATION

USDA

FAX NUMBER

TRAP DATA
6. DATE COLLECTED

7. DATE OF LAST TRAP CHECK

8. TRAP NUMBER

9. NEAREST PORT OF ENTRY (Including Military Bases)

10. TRAP TYPE
Delta

Milk Carton

Light Trap

11. TRAP LOCATION
Address

Other __________________________________________________
12. APPROXIMATE NUMBER OF SPECIMENS IN TRAP

Town or City (or nearest one)

13. OTHER LIFE STAGES COLLECTED (If submitted check
appropriate box and indicate approximate quantity)

State

Eggs _______________
County

(IMPORTANT: One egg mass per
specimen bag. DO NOT mix egg masses)

ZIP code
Larvae ______________
Pupae ______________

Longitude (if available)

Latitude (if available)

Other Coordinates
Female Adult ______________

14. SPECIAL TREATMENTS OF SPECIMENS (e.g., freezing conditions, use of alcohol, prolonged storage conditions, host if no trap used, etc.)

15. SEND TO

16. DATE SENT
MOLECULAR DIAGNOSTICS
USDA, APHIS, PPQ
OTIS CPHST LABORATORY
1398 WEST TRUCK ROAD
BUZZARDS BAY, MA 02542

Telephone Number:
508-563-0900
Fax Number:
508-563-0903

FOR LABORATORY USE ONLY
DATE RECEIVED

PPQ FORM 305
AUG 2014

OTIS ID NUMBER

Previous edition is obsolete.