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 |
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District |
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Division |
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Location |
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Sub- location |
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Village/ Estate |
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GPS Location |
Lat |
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Current Location of Herd at time of visit: |
Central collection point |
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Other: |
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Long |
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Herd’s current grazing ground |
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Please use decimal degrees format (example: S 01.31482 o, E 036.80287 o )
Herd Owner’s NAME: |
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Purpose of visit: |
Vaccination |
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Investigation of Suspect herd |
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Survey/ Routine Surveillance Visit |
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Other (specify): |
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Animals kept in Herd |
Cattle |
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Sheep |
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Goats |
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Camels |
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Donkeys |
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Herd Movement |
Sedentary |
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Nomadic/ pasturalist |
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Trade |
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Other (specify) |
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Herd Grazing Pattern |
Common |
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Enclosed |
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Zero |
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Other (specify) |
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Has herd recently moved from another location? |
No |
Yes |
If yes, provide details (previous location, date of movement, reason) |
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Have there been any reports of RVF among people in area? |
No |
Yes |
Source of information (such as local rumor, health facility – please specify) |
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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)
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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 |
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Sheep |
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Goats |
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Camels |
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Donkey |
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Other: |
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Herd Treatment (Describe interventions below)
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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 |
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Goats |
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Camels |
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Donkey
Other: |
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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
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Comments: |
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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
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Comments: |
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Purpura, Lawrence James (CDC/OPHSS/CSELS) |
File Modified | 0000-00-00 |
File Created | 2021-01-23 |