VS Form 10-3 Request For Salmonella Serotyping

Clear 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 0579-0007. The time required
to complete this information collection is estimated to average .16 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
NATIONAL VETERINARY SERVICES LABORATORIES
AMES, IA 50010
1. SUBMITTER (business name and name of individual contact)

OMB Approved
0579-0007
EXP: XX/XXXX

REQUEST FOR SALMONELLA SEROTYPING

2. NVSL SUBMITTER ID

EMAIL ADDRESS

3. HERD/FLOCK OWNER

OWNER CITY & STATE

PHONE NO.

FAX NO.

SUBMITTER ADDRESS (street, city, state, ZIP code)

PREMISES ID
4. EXAMINATIONS REQUESTED
SEROTYPING

PHAGETYPING

PFGE

SE RULE OUT

OTHER (specify in Block 15)

5. NATIONAL POULTRY
IMPROVEMENT PLAN
(NPIP)
YES

6. ACCESSION/REFERRAL
NUMBER

7. PAYMENT METHOD
USER FEE ACCOUNT NUMBER

CHECK/MONEY ORDER

CREDIT CARD (number and expiration date)

(enclosed, payable to USDA in U.S. dollars)

8. SPECIES OR SOURCE
Cattle

Goat

Chicken

Zoo (specify)

Food (specify)

Swine

Horse

Turkey

Wildlife (specify)

Foodstuffs

Sheep

Reptile (specify)

Other Bird (specify)

Environment (specify)

Egg Pool

Other (specify)

Additional Description / Specification:

9. CLINICAL ROLE
INFECTION

MONITOR/ENVIRONMENT

10. SPECIMEN CULTURED

RESEARCH

11. CULTURE NO.

OTHER (specify)
12. O GROUP

13. SEROTYPE

14. PHAGE TYPE

A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
15. COMMENTS / SPECIAL INSTRUCTIONS

16. SUBMITTED BY (name and title)

17. DATE SUBMITTED
NVSL ACCESSION NO
(NVSL USE ONLY)

SEROTYPED BY:

VS FORM 10-3
OCT 2018

VS FORM 10-3 INSTRUCTIONS
ALL information must be printed legibly or typed. Use a separate form for each species and owner.
1. SUBMITTER CONTACT INFORMATION
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, clearly indicate special
instructions.
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
Enter the complete name, city, and state of the herd/flock owner. Ensure the animal owner is identified here and not the property manager or veterinarian. If a
National Animal Identification System premises ID number has been assigned to the location of the animals, it may be entered.
4. EXAMINATIONS REQUESTED
Indicate the type of examination requested.
5. NATIONAL POULTRY IMPROVEMENT PLAN
Check the indicated box if the samples are being submitted as part of the National Poultry Improvement Plan (NPIP).
6. ACCESSION/REFERRAL NUMBER
This number is typically assigned by the submitter and is used for the submitter’s own reference.
7. PAYMENT METHOD
If the requested testing is billable, 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.
8. SPECIES OR SOURCE
Check only one block. If specimens are from different species or sources, use a separate VS Form 10-3 for each source. Space is provided at the right side of
this field to add detailed information when a general source category is selected and additional specification is requested.
9. CLINICAL ROLE
10. SPECIMEN CULTURED
Enter the specimen/tissue from which the culture was derived.
11. CULTURE NUMBER
Ensure that the identification entered here exactly matches the number placed on the culture container.
12-14. O GROUP, SEROTYPE, and PHAGE TYPE
For NVSL use only.
15. COMMENTS/SPECIAL INSTRUCTIONS: Use this space to enter any special instructions, including non-standard delivery of the test report.
16. SUBMITTED BY and 17. DATE SUBMITTED
The individual submitting the culture(s) must sign and date the form.