Form PPQ-391 Insect Collection Worksheet for Genotype Analysis

This report is authorized by law
(7 U.S.C. 147a). While you are not
required to respond, your cooperation
is needed to make an accurate record
of plant pest conditions.

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 0579-0377 and 0104. The time required to complete this information collection is estimated to average
between .17 and .25 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

SPECIMENS FOR DETERMINATION
1. COLLECTION NUMBER

Instructions: Type information requested. Block 1 – assign a number for each collection using
your own numbering convention or use the following example by beginning with the year, followed
by the collector’s initials and the collector’s number. Example: 14-JJD-001.

OMB APPROVED
0579-0010 and 0104
EXP. DATE
07/2020

LOT NUMBER

ROUTINE

Pest Data Section – Complete Blocks 14, 15 and 16. Complete Items 17 and 18 if a trap was used.

2A. DATE - SUBMISSION
MONTH
DAY
YEAR

2.B. DATE - COLLECTION
MONTH
DAY
YEAR

3. SUBMITTING AGENCY
State Cooperator

PRIORITY
URGENT
PROMPT

University

APHIS PPQ

4A. NAME OF SUBMITTER

4B. NAME OF COLLECTOR

6. TYPE OF PROPERTY (FARM, RESIDENCE, NURSERY. ETC.)
INTERCEPTION SITE

SUBMITTER AND ORIGIN

Other:

5. ADDRESS OF SUBMITTER

ZIP
EMAIL ADDRESS OF SUBMITTER

7. NAME AND ADDRESS OF PROPERTY OWNER

CITY

COUNTY

STATE

LATITUDE

LONGITUDE

PURPOSE

8. REASON FOR IDENTIFICATION (“X” all applicable items)
A.

Biological Control (Target Pest Name _____________________________)

E.

Export Certification

B.

Damaging Crops/Plants

F.

Targeted Survey (Pest Name
_________________________________)

C.

Suspected Pest of Regulatory Concern (Explain in REMARKS)

G.

Smuggling Interdiction/Trade Compliance (SITC)

D.

Stored Product Pest

H.

Other (Explain in REMARKS)

9. IF PROMPT OR URGENT IDENTIFICATION IS REQUESTED, PLEASE PROVIDE A BRIEF EXPLANATION UNDER “REMARKS”.
10. HOST INFORMATION

11. QUANTITY OF HOST

NAME OF HOST (Scientific name and name of cultivar if appropriate)

NUMBER OF ACRES/PLANTS

Plant affected (insert figure and indicate)

HOST DATA

Number:
Percent:
12. PLANT DISTRIBUTION

13. PLANT PARTS AFFECTED

Limited

Leaves, Upper Surface

Trunk/Bark

Bulbs, Tubers, Corms

Leaves, Lower Surface

Branches

Buds

Petiole

Growing Tips

Flowers

Seeds

Scattered
Widespread
14. PEST DISTRIBUTION

PEST DATA

FEW
COMMON

Stem
15.
NUMBER
SUBMITTED

ABUNDANT

ALIVE

EXTREME

DEAD

16. SAMPLING METHOD

Roots

Fruits or Nuts

INSECTS
LARVAE

NEMATODES
PUPAE

CAST
SKINS

ADULTS

17. TYPE OF TRAP AND LURE

MOLLUSKS
EGGS

NYMPHS

JUVS.

18. TRAP NUMBER
METHOD
MORPHOLOGY

19. REMARKS

SYMPTOM
CULTURE
SEROLOGICAL
PCR
SEQUENCING
20. TENTATIVE DETERMINATION

DETERMINED BY

POSITION AND AFFILIATION

METHOD

21. FINAL DETERMINATION AND NOTES (NOT FOR FIELD USE)

MORPHOLOGY
SYMPTOM
CULTURE
SEROLOGICAL
PRINT NAME

DISPOSITION OF SPECIMEN/SAMPLE
Returned

SIGNATURE

PPQ Form 391
DEC 2017

DATE

Retained for
Collection/Stored

Transferred to:
________________
LAB CONFORMATION NUMBER
Destroyed

Previous editions are obsolete.

PCR
SEQUENCING
DATE RECEIVED

CYSTS

INSTRUCTIONS
Use PPQ Form 391, Specimens for Determination, for domestic collections (warehouse inspections, local and individual
collecting, special survey programs, export certification).
BLOCK

INSTRUCTIONS
1. Assign a number for each collection using your own numbering convention or use the
following example by beginning with the year, followed by the collector’s initials and the
collector’s number.

1

EXAMPLE

In 2014, Brian K. Long collected his first specimen of the year for
determination. His first collection number is 14-BLK-001

2. Enter the collection number
2A-2B
3
4A
4B
5
6
7
8A-8H
9
10
11
12
13
14
15
16
17
18
19
20
21

Enter dates
Check block to indicate Agency submitting specimens for identification
Enter name of submitter
Enter name of collector
Enter address of submitter
Enter type of property specimen obtained from (farm, nursery, residence, etc.)
Enter name and address of property owner
Check all appropriate blocks
Leave Blank
Enter scientific name of host, if possible
Enter quantity of host and plants affected
Check block to indicate distribution of plant
Check appropriate blocks to indicate plant parts affected
Check block to indicate pest distribution
Check appropriate block to indicate type of specimen
Enter number specimens submitted under appropriate column
Enter sampling method
Enter type of trap and lure
Enter trap number
Provide a brief explanation if Prompt or URGENT identification is requested
Enter a tentative determination and who made it
Leave blank

Distribution of PPQ Form 391
Distribute PPQ Form 391 as follows:
1. Send Original along with the sample to your Area Identifier or for national confirmation.
2. Retain and file a copy for your records.

PPQ Form 391 Reverse