VS 10-4 Specimen Submission

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 0579-0090, 0101, 0212, and 0324. The time required to complete this information collection is estimated to average .5 hours per response for 0579-0090, 1 hour per response for 0579-0101, and .25 hours per response for 0579-0212 and 0324, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

OMB Approved

0579-0090, 0579-0101, 0579-0212, and 0579-0324

UNITED STATES DEPARTMENT OF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECTION SERVICE NATIONAL VETERINARY SERVICES LABORATORIES P.O. BOX 844, 1920 DAYTON AVENUE, AMES, IA 50010 (515) 337-7514

SPECIMEN SUBMISSION

PAGE OF

INSTRUCTIONS: Use a separate form for each species and each owner/broker. See “Instructions for Completing VS Form 10-4” for definitions.

1. SUBMITTER NAME (including Business Name)

2. NVSL SUBMITTER ID

3. NAME OF OWNER Check if wildlife (no owner)

EMAIL ADDRESS

OWNER CITY

STATE/COUNTRY

PHONE NO. FAX NO.

4. LOCATION OF ANIMALS

MAILING ADDRESS (Street, City, State, ZIP Code)

PREMISES ID

COUNTY

STATE/COUNTRY

5. PAYMENT METHOD

USER FEE ACCOUNT NO.

CHECK/MONEY ORDER

(Enclosed, payable to USDA in US dollars)

Number:

CREDIT

CARD Exp. Date:

6. HERD/FLOCK SIZE

9. EXAMINATIONS REQUESTED

10. COLLECTED BY

7. NO. IN HERD/FLOCK AFFECTED

11. DATE COLLECTED

8. NO. IN HERD/FLOCK DEAD

12. AUTHORIZED BY

13. PURPOSE OF SUBMISSION (See instructions for definitions)
Interstate Movement	Import	TB	Reagent Evaluation
Export	FAD/EP Diagnostic	General Diagnostic	NVSL Intralab
Pre-Import	Surveillance	Developmental Research

14. COUNTRY OF ORIGIN

15. REFERRAL NUMBER

16. PRESERVATION

None Ice Pack Dry Ice Formalin Borax Alcohol Other (Specify)

17. SPECIMENS SUBMITTED (“X” applicable item(s))
Blood	Feces	Parasite	Serum	Tissue (specify)	Whole Animal	Other (specify)
Culture	Feed	Plant	Soil	Urine	Fetus
Extract	Milk	Semen	Swab (specify)	Water	DNA/RNA

18. TOTAL NUMBER OF SPECIMENS SUBMITTED

19. SPECIES OR SOURCE (“X” ONLY one)
Cattle	Goat	Chicken	Bison	Fish	Other (specify)
Swine	Horse	Turkey	Deer (specify)	Environment
Sheep	Donkey	Other bird (specify)	Elk	Reagent

20. NUMBER OF ANIMALS SAMPLED

21. IDENTIFICATION (See instructions <250 samples per form>)

IDENTIFICATION

Sample ID

Animal ID

Breed

Age

Sex

Sample ID

Animal ID

Breed

Age

Sex

22. ADDITIONAL DATA (History, clinical signs, post mortem findings, remarks, tentative diagnosis, special instructions. Use additional sheets if necessary).

23. SIGNATURE OF SUBMITTER AND DATE

X

NVSL USE ONLY

NVSL USE ONLY

CONDITION

PRIORITY

DISTRIBUTION

RECEIVED BY

VS FORM 10-4

AUG 2009

VS FORM 10-4 INSTRUCTIONS

ALL information must be printed legibly or typed. Use a separate form for each species and owner. At the minimum, complete all fields designated in these instructions as required. Contact the Receiving Department of the laboratory to which you are sending specimens with specific documentation or shipping questions.

If including more than one page, include the page number of total pages submitted (e.g., 1 of 3).

1. SUBMITTER CONTACT INFORMATION “REQUIRED”

Enter the submitter’s business name/affiliation; the name of the individual submitter is optional if test results are returned to a general business fax, email, or mailing address. Enter a fax number or email address to which we can return test results. Multiple email addresses are permissible. Specify if there is a preferred method of report delivery; email will be used if no preference is stated. Provide a complete mailing address. If fax or email is not available, test reports can be mailed, but this will delay delivery of your results. Repeat submitters are encouraged to be consistent with the submitter contact information that they provide, as the NVSL keeps a master record. If the test report for an individual submission needs to be routed to a non-standard destination, include special instructions in Block 22, Additional Data.

2. NVSL SUBMITTER ID

For more efficient service, repeat submitters are encouraged to include their NVSL Submitter ID. If you do not know your ID, contact the NVSL at

(515) 337-7514.

3. OWNER INFORMATION “REQUIRED”

Enter the complete name of the animal owner, the city and the two-letter abbreviation of the State in which the owner resides. Ensure the animal owner is identified here and not the property manager or veterinarian. For wildlife, check the box to indicate there is no owner.

4. LOCATION OF THE ANIMALS “REQUIRED”

Include National Animal Identification System (NAIS) premises ID if available. Also, specify the county, parish or other designated location of the animals and the two-letter State abbreviation.

5. PAYMENT METHOD “REQUIRED FOR BILLABLE CASES”

Check the appropriate payment method. If payment is by user account or credit card, enter the account number. Enter the expiration month and year when using a credit card. Refer to the User Fees/Payment Options and the Catalog of Services/Fees, both located at www.aphis.usda.gov/animal_health/lab_info_services/diagnos_tests.shtml, for specific test fees and a list of accepted credit cards. DO NOT SEND CASH.

6. HERD/FLOCK SIZE

Enter the total number of animals in the herd/flock.

7. NO. IN HERD/FLOCK AFFECTED

Enter the total number of animals in direct contact with suspect animal or showing clinical signs.

8. NO. IN HERD/FLOCK DEAD

Enter the total number of animals, from this herd/flock that are dead.

9. EXAMINATIONS REQUESTED “REQUIRED”

For disease programs, it is necessary only to enter the program name (e.g., CWD, Scrapie, or BSE). If the test is not for a disease program, specify the disease and the desired test.

10. COLLECTED BY

Enter the complete name of the person collecting the specimen(s).

11. DATE COLLECTED

Enter the date on which specimens were collected. Use the format DD/MM/YYYY.

12. AUTHORIZED BY

Enter the name of the person authorizing the submission of this sample. Normally, this is the Area Veterinarian in Charge (AVIC) in your State. Authorization is assumed for regulatory veterinarians making routine program specimen submissions. See http://www.aphis.usda.gov/animal_health/area_offices/ to locate the AVIC in your local area.

If an exotic (foreign) disease is suspected, contact the AVIC and the Emergency Programs staff to obtain authorization to submit samples for FAD testing and an investigation control number that must be included with the submission. DO NOT ship any such specimens until approval is received and a control number is assigned. The receipt of an unauthorized shipment of specimens containing exotic disease agents can cause substantial disruption of work at the laboratory and result in possible fines for the submitter.

13. PURPOSE OF SUBMISSION “REQUIRED”

Definitions of Diagnostic Case Categories are as follows:

Interstate Movement – Tests conducted for the purpose of qualifying live animals or poultry for interstate movement.

Export – Tests conducted for the purpose of qualifying animals or poultry, including wild animals and birds, or animal or poultry products for export from the U.S. to a foreign country.

Pre-Import – Tests conducted for the purpose of qualifying animals or poultry, including wild animals and birds, or animal or poultry products for import into the U.S. Select this purpose when the animals or products have not yet been moved into the U.S.

Import – Tests conducted for the same purpose as pre-import except that the animals or products are currently located at a U.S. import center.

FAD/EP Diagnostic – Tests conducted for the purpose of diagnosing or confirming a foreign disease, or for the eradication of a foreign disease that has gained entrance into the U.S. If a foreign animal disease is suspected, follow instructions in Block 12 for authorization to submit a FAD specimen.

Surveillance – Tests conducted for monitoring for a specific disease, for a specific insect or insect vector, or for analyzing specific products that are used in treating animals or poultry or for decontamination of animal poultry facilities.

TB – Tests conducted for diagnosing Tuberculosis.

General Diagnostic Case – Tests conducted for the purpose of diagnosing or confirming a domestic disease, and/or the analysis of environmental products that may be contributing to an existing disease condition. Use this purpose when the purposes listed above do not apply.

Developmental/Research – Tests conducted for the purpose of supporting a developmental or research project conducted by staff or field personnel of VS or by other laboratories, institutions, or agencies.

Reagent Evaluation – Tests conducted for the purpose of evaluating a reagent produced by other laboratories, institutions, or agencies.

NVSL Intralab – Tests conducted for another laboratory of the NVSL.

14. COUNTRY OF ORIGIN/DESTINATION

For import or pre-import cases, enter the country in which the animals last resided. For export cases, enter the country to which the animals will be shipped.

15. REFERRAL NUMBER

This number is typically assigned by the submitter and is used for the submitter’s own reference. In FAD cases, enter the investigation control number described in the instructions for Block 12.

16. PRESERVATION

Check all blocks that apply.

17. SPECIMENS SUBMITTED “REQUIRED”

Check all blocks that apply.

18. TOTAL NUMBER OF SPECIMENS SUBMITTED

Enter the total number of specimens submitted. Specimens in one container are counted as one sample. Please limit to <250 samples per submission.

19. SPECIES OR SOURCE “REQUIRED”

Check only one block. If specimens are from different species or sources, use a separate VS Form 10-4 for each source. Reminder: Enter the animal BREED in Block 21.

20. NUMBER OF ANIMALS SAMPLED

Enter the total number of animals sampled.

21. IDENTIFICATION “REQUIRED”

Sample ID – Identify samples with consecutive numbers. Ensure the sample identification number on this form matches the sample identification number placed on the specimen container.

Animal ID – Record the animal’s national identification tag number adjacent to the appropriate sample number. If there is no national animal ID, record the most appropriate identification number (or name). NOTE: Laboratory results will be reported by animal identification number.

Breed – Enter the animal breed (e.g., Holstein, Angus).

Age – Indicate the approximate age in years (y), months (m), weeks (w), or days (d).

Sex – Indicate the sex, male (M), or female (F), for each animal.

22. ADDITIONAL DATA

Enter all pertinent information about the animals and premises that can assist the lab in making a diagnosis.

• Provide detail on tissue specimens you are including (e.g., lymph nodes, obex, brain)

• Specify clinical signs (e.g., weight loss, hair missing)

• If meat is being retained pending specimen results, enter RETAINED

• Add related case submission numbers to assist in trace activities

• Include any information that did not fit into its designated space elsewhere on the form

• Include any special (non-standard) instructions for test report delivery

23. SIGNATURE OF SUBMITTER AND DATE

The individual submitting the specimen(s) must sign and date the form.

VS Form 10-4 (Reverse)