VS 17-131 BSE Surviellance Data Collection Form

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 0579-0409. The time required to complete this information collection
is estimated to average .1 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.

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES

OMB APPROVED
0579-0409
EXP.: 10/2016

BSE SURVEILLANCE DATA COLLECTION FORM

***THIS FORM MUST BE USED IN CONJUNCTION WITH VS 17-146 (BSE SURVEILLANCE SUBMISSION FORM). DO NOT SUBMIT ALONE.***
1. PRIMARY REASON FOR SUBMISSION (check the selection with the smallest number that applies)
1. Highly suspicious for BSE
5. Nonambulatory/Disabled/Downer
2. FSIS, antemortem condemned cattle
6. Other clinical signs that may be associated with
3. Rabies suspect
BSE as noted below
4. CNS signs
7. Dead
3. INDIVIDUAL DETERMINING PRIMARY REASON (BLOCK 1) AND CLINICAL SIGNS (BLOCK 13) (select one)
1. Veterinarian employed by APHIS
5. Renderer/deadstock hauler/3D-4D
2. Veterinarian employed by FSIS
6. Producer/owner
3. Other Veterinarian
7. Other (describe in Block 10)
4. Other APHIS personnel

2. BSE Referral Number
(must agree with # on VS 17-146)

4. BSE Sample ID

Please use barcode, if available

Name (including Business Name)

6. SLAUGHTER SITE OR √
if same as Collection Site on VS 17-146
(complete only if slaughtered at State or FSIS-inspected facility)
Premises ID or FSIS Plant Number

Street

Name (including Business Name)

5. OWNER INFORMATION

City

State

ZIP Code

Street

Country (if not USA)

Premises ID or Lat/Long

City

Phone

Fax

Phone

County

Email

Email

7. ANIMAL INFORMATION
a. Animal Breed (if known)
b. Age_______
If breed not known:
Beef Breed
Dairy Breed

State
Fax

Months

Age is:

Years
Primary Colors:

e. Country of Origin (only if
KNOWN to be other than USA)

Estimated
Recorded

nd

Dentition: 2 Set of Incisors Erupted

f. Official USDA Tag No.

ZIP Code

c. Gender
Female
Male
Unknown

d. Neutered
Yes
No
Unknown

Yes
No

g. FSIS Condemnation Tag No.

h. Back Tag No.

i. Microchip No.

l. Owner Ear Tag No.

m. Other ID No.

Zj. Collection Site Tracking No.

k. Slaughter Tracking No.

8. CLINICAL SIGNS (select all that apply)
Abnormal head carriage
Head pressing/rubbing
Aggressive or belligerent
Head shyness
Apprehensive or nervous
Hyperesthesia (sensitivity to light or sounds,
shifting ears)
Ataxia (abnormal gait,
Hesitation at doors, gates, or barriers
uncoordinated)
Blindness
Kicking while milking (when did not before)
Circling
Paralysis
Droopy lip or eyelid
Tremors or nystagmus
Excessive bellowing
(includes eye movements, head tremors)
Excessive licking
Excitable

→

Signs marked at left:
Worsened over time
Did not worsen
Don’t know

→

The animal:
Responded to treatment
Did not respond
Don’t know

Other signs observed:
Depressed
Dead of unknown cause
Loss of weight over time
Recumbency
(nonambulatory/down)
Reduced milk yield over time
Other (note in Block 10)

9. FSIS CONDEMNATION CODES (select one – ONLY if FSIS has made one of these designations)
Degen and Dropsic
Actinomycosis and Actinobacillosis
Misc. Infectious dz.
Arthritis
Mastitis
Metritis
Pericarditis
Pneumonia
10. ADDITIONAL DATA/COMMENTS

VS 17-131
FEB 2014

099
101
199
201
203
204
206
208

Misc. inflamm dz.
Epithelioma
Malig lymphoma
Misc. neoplasms
Abscess/pyemia
Septicemia
Toxemia
Nonambulatory

299
302
303
399
501
502
503
445

Injuries
Pigment conditions
Myiasis
General misc.
Residue
Other reportable dz.
Misc. parasitic cond.

605
607
402
699
609
900
499

Tetanus
Vesicular dz.
CNS disorders
Dead
Moribund
Pyrexia
Rabies

105
110
601
603
606
608
615

VS FORM 17-131 INSTRUCTIONS
This is a companion form to VS Form 17-146 (BSE
Suveillance Submission Form) and should always be
accompanied by VS 17-146. Complete this form for each
animal listed on VS 17-146.
1. PRIMARY REASON FOR SUBMISSION
Use professional judgment to select the one reason that best
describes why this sample is being taken. If more than one
reason applies, check the reason with the smallest associated
number.

•
•

•
•
•
•
•

Highly suspicious for BSE: animal being sampled
demonstrates clinical signs of, or has a clinical history
consistent with, the definition of “highly suspicious for BSE”
as described in VS Memo 580.16.
FSIS, antemortem condemned cattle: animals condemned
by FSIS personnel prior to slaughter and sampled at the
slaughter plant or at an offsite collection facility. (Note: If
selected, an FSIS Condemnation Code must also be
selected in Block 9.)
Rabies suspect: animals initially identified for rabies testing
because of clinical signs or clinical history, as described in
VS Memo 580.16.
CNS signs: animal has central nervous system (CNS) signs
consistent with primary CNS disease, but does not meet all
the criteria for classification as Highly Suspicious for BSE.

7. ANIMAL INFORMATION

•
•

•
•
•
•

Breed: Enter apparent breed of animal. If unknown, check
whether beef or dairy breed and include animal’s primary
colors.
Age: Enter the animal’s age as the number of months or the
number of years (whole numbers only). If purebred records
or other official sources are used to calculate the animal’s
age, check the “Recorded” box. Otherwise, check the
“Estimated” box.
Dentition: Examine the animal’s mouth and check “Yes” if at
least one of the second incisors has erupted.
Gender and Neuter Status: Check the appropriate box.
Country of Origin: If it is known that the animal originated
from a country other than the United States, write the name
of the country in the space provided.
Animal ID: In the appropriate boxes, enter ALL types of
animal identification devices, brands, and tattoos associated
with the sampled animal.

•
•
•

Nonambulatory/Disabled/Downer: animal sampled primarily
because it is nonambulatory, periodically or continuously.
Other clinical signs that may be associated with BSE:
animal demonstrates clinical signs that may be consistent
with BSE, such as emaciation, tetanus (tetany), or injuries.

•

Dead: available history only indicates that the animal is
dead, with none of the preceding conditions described above

2. BSE REFERRAL NUMBER
This number must correspond to the number listed on the related
VS Form 17-146. See instructions for VS 17-146 for details on
preferred numbering format.
3. INDIVIDUAL DETERMINING REASON/SIGNS
Check the box that best describes the individual who determined
the primary reason for this submission and the clinical signs for
the animal identified on this form. If “Other” is selected, describe
in Block 10.

•
•

Record all letters in upper case (capitalize).
Substitute an underscore (_), without additional spaces,
for each unreadable character in the identification.
Official USDA tags (e.g., USDA bright metal eartag,
brucellosis vaccination eartag, Animal Identification
Number (AIN) eartag, bangle eartag). If an animal has
more than one official USDA identification, enter
additional identifications in Block 10.
Nonofficial tags: Indicate the color of the tag, according
to the key below, followed by whatever is written on the
tags. For multi-colored tags, include all colors.
Y=yellow
R=red
G=green W=white
B=blue
O=orange
P=pink
T=tan/brown
S=silver
K=black
A=gray
L=lavender/purple
Brands (hot iron or freeze): Describe to the best of your
ability. Include the location of the brand on the animal.
Tattoos: Indicate which ear (R=right, L=left) or other
location and include all characters.

4. BSE SAMPLE ID
Add the Sample ID barcode for which the animal information on
this form applies. See instructions for VS 17-146 for details on
barcode availability and distribution.

8. CLINICAL SIGNS
Check all signs that apply. At least one sign must be checked.
Be thorough and complete. Obtain information directly from
animal handlers/owners whenever possible. Use professional
judgment and ensure that contradictory signs are not checked.
Indicate whether the signs were progressive (worsened over time)
and whether they were responsive to treatment. Clinical signs are
important to determine the significance of each sample in the
surveillance program.

5. OWNER INFORMATION
Enter known information for the premises on which the sampled
animal was last held or resided. At a minimum, provide the
State or county.

9. FSIS CONDEMNATION CODES
Complete this section ONLY if “FSIS, antemortem condemned
cattle” was selected in Block 1. Select only one condemnation
code.

6. SLAUGHTER SITE
This block pertains ONLY to animals slaughtered at a State- or
FSIS-inspected facility. Mark the box if the slaughter site is the
same as the collection site described in Block 3 of the
accompanying VS Form 17-146. Otherwise, enter all requested
information about the slaughter site.

10. ADDITIONAL DATA/COMMENTS
Use this block if there is insufficient space in other blocks or to
add any relevant information.