Form 10-11 Equine Infectious Anemia Laboratory Test

See reverse for more OMB information.

FORM APPROVED - OMB NUMBER 0579 - 0127

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE

SERIAL NO.

1. ACCESSION NUMBER

2. DATE BLOOD
DRAWN

T

EQUINE INFECTIOUS ANEMIA LABORATORY TEST
(VS Memorandum 555.16)

Forms Without Adequate Descriptions Of The Horse And Complete Addresses Including ZIP Codes, Counties, And
Telephone Numbers Will Not Be Processed.
3. REASON FOR TESTING

Market

Change of Ownership

4. GEOGRAPHIC INFORMATION
SYSTEMS (GIS)

Show

First Test

Retest

Export

7. NAME AND ADDRESS OR STABLE/MARKET (Please print or type)

6. TEST TYPE

5. VETERINARY LICENSE OR
ACCREDITATION NO.

ELISA

LAT:
LONG:

ZIP Code

AGID

County

Tel No.

8. NAME AND ADDRESS OF OWNER (Please print or type)

9. NAME AND ADDRESS OF VETERINARIAN (Please print or type)

ZIP Code

ZIP Code

County

Tel No.

County

Tel No.

CERTIFICATION OF FEDERALLY ACCREDITED VETERINARIAN
I certify the specimen submitted with this form was drawn by me from the horse described below on the date indicated above.
11. TYPE OR PRINT SIGNATURE NAME

10. SIGNATURE OF FEDERALLY ACCREDITED VETERINARIAN

12. SIGNATURE DATE

CERTIFICATION OF OWNER OR OWNER'S AGENT
I certify that I have examined this form and, to the best of my knowledge and belief, this form is true, correct, and complete.
13. SIGNATURE OF OWNER OR OWNER'S AGENT

16 .
Tube
No.

17.
Official
Tag

18.

14. TYPE OR PRINT SIGNATURE NAME

19.
Name of Horse

Tattoo/Brand

20.
Color

15. SIGNATURE DATE

22.
Electronic
I.D. No.

21.
Breed

23.
Age or
DOB

24.
Sex

M - Male
F - Female
G - Gelding
SF-Spayed
Female

SHOW ALL SIGNIFICANT MARKINGS, WHORLS, BRANDS, AND SCARS

5

5
4

4
3

3

3

3
1

2

2

1

2

2
1 - Coronet, 2 - Pastern, 3 - Fetlock, 4 - Knee, 5 - Hock

NARRATIVE DESCRIPTION AND REMARKS
25. HEAD

26. OTHER MARKS AND BRANDS

27. LEFT FORELIMB

28. RIGHT FORELIMB

29. LEFT HINDLIMB

30. RIGHT HINDLIMB

FOR LABORATORY USE ONLY
31. LABORATORY NAME/CITY/STATE

32. DATE RECEIVED

33. DATE REPORTED OUT

34. TEST RESULTS

Negative
35. SIGNATURE OF TECHNICIAN

Positive

AGID

ELISA

36. REMARKS

Falsification of this form or knowingly using a falsified form is a criminal offense and may result in a fine of not more than $10,000 or
imprisonment for not more than 5 years or both (U.S.C. Section 1001).
VS FORM 10-11 (MARCH 2014)

COPY DESIGNATIONS

PART. 1 - VETERINARIAN/SUBMITTER
PART. 2 - LABORATORY OFFICE
PART. 3 - OWNER
PART. 4 - VETERINARY SERVICES ASSISTANT DISTRICT DIRECTOR
PART. 5 - STATE

EQUINE INFECTIOUS ANEMIA LABORATORY TEST

VS FORM 10-11
(MAY 2003)

USDA - APHIS

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collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is
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information.

VS FORM 10-11
REVERSE

TOP STUB INSTRUCTIONS

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

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