Livestock Assessment Form

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Livestock Assessment Form

This form should accompany the samples to the laboratory and copies should be submitted to _________

Team Leader:

General Description:

Team Number:

DATE of visit: ^{/ /}

Day Month Year

Province

District

Division

Location

Sub- location

Village/ Estate

GPS Location

Lat

Current Location of Herd at time of visit:

Central collection point

Other:

Long

Herd’s current grazing ground

Please use decimal degrees format (example: S 01.31482 ^o, E 036.80287 ^o )

Herd Description:

Herd Owner’s NAME:
Purpose of visit:	Vaccination		Investigation of Suspect herd		Survey/ Routine Surveillance Visit			Other (specify):
Animals kept in Herd	Cattle	#	Sheep	#			#		#		#
					Goats			Camels		Donkeys
Herd Movement	Sedentary		Nomadic/ pasturalist		Trade			Other (specify)
Herd Grazing Pattern	Common		Enclosed		Zero			Other (specify)
Has herd recently moved from another location?	No	Yes 	If yes, provide details (previous location, date of movement, reason)
Have there been any reports of RVF among people in area?	No	Yes 	Source of information (such as local rumor, health facility – please specify)

Public reporting burden of this collection of information is estimated to average 30 minutes 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. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)

Herd Health Status (Describe herd health status below)

	Healthy? (Y/N) If no, then fill in	Unusual # Abortions? (# affecte d or zero)	Unusual # Stillbirths? (# affected or zero)	Unusual # Deaths -Young? (# affected or zero)	Unusual # Deaths -Adult? (# affected or zero)	Other unusual health problem – specify (# affected or zero)	Date problem first noted
Cattle
Sheep
Goats
Camels
Donkey
Other:

Additional comments: (IF NO RVF CLINICAL SIGNS FILL IN ZERO REPORT HERE)

Herd Treatment (Describe interventions below)

	RVF Vaccine (# treated or zero)	LSD Vaccine (# treated or zero)	CCPP Vaccine (# treated or zero)	Pour -on insecticide (# treated or zero)	Other (Specify) (# treated)	Samples taken (# taken or zero)
Cattle Sheep
Goats
Camels
Donkey Other:
Specify any other treatments/vaccinations applied:

No.	Animal ID	Health Status: S=sick; H = healthy; A = recently aborted; PM = post-mortem;	Species: B=cattle; G=goats; S=sheep; C=camel; D=donkey; O=other (specify)	Gender: M = male; F = female; C = castrate	RVF Vaccination: Yes/No/ Unknown	Sample Submitted: WB = Whole Blood; S = Serum; T = tissue	Serology Results IgM/IgG: P=Positive N=Negative	Comments:
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Add additional pages as needed

No.	Animal ID	Health Status: S=sick; H = healthy; A = recently aborted; PM = post-mortem;	Species: B=cattle; G=goats; S=sheep; C=camel; D=donkey; O=other (specify)	Gender: M = male; F = female; C = castrate	RVF Vaccination: Yes/No/ Unknown	Sample Submitted: WB = Whole Blood; S = Serum; T = tissue	Serology Results IgM/IgG: P=Positive N=Negative	Comments:
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