Vs 5-29A Scrapie Test Record - Continuation Sheet

Scrapie in Sheep and Goats; Interstate Movement Restrictions and Indemnity Program

VS 5-29A DEC 2011

State, Local, or Tribal Government

OMB: 0579-0101

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The valid OMB control number for this information collection is 0579-0101. The time required to complete this information collection is estimated to average .3 hours per response, including the time for
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U.S. DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES

FLOCK OWNER'S NAME - LAST

Specimen #

SCRAPIE TEST RECORD
CONTINUATION SHEET
Complete all entries on VS Form 5-29 before using this form.
FIRST

Official ID Number

NOTE: Sample numbers on specimens must be the same as listed on
this form.

INITIAL

FLOCK ID

Designation
(pos, sus,
exp, me,
n/a)

OMB APPROVED
0579-0101
EXP DATE XX/XXXX

__ of __
VETERINARIAN

DATE
COLLECTED

Other ID Numbers

PAGE NO.

Age

Sex
(f,m,cm)

Breed
(if unknown,
face color)

3rd Eyelid Info

L

R

Seen
Unseen

L

R

Seen
Unseen

L

R

Seen
Unseen

L

R

Seen
Unseen

L

R

Seen
Unseen

L

R

Seen
Unseen

L

R

Seen
Unseen

L

R

Seen
Unseen

L

R

Seen
Unseen

L

R

Seen
Unseen

L

R

Seen
Unseen

L

R

Seen
Unseen

L

R

Seen
Unseen

L

R

Seen
Unseen

L

R

Seen
Unseen

L

R

Seen
Unseen

Circle if the 3rd eyelid tissue came from the Left or Right
eye. Circle if the lymphoid tissue was Seen or Unseen

Remarks:

Circle if the 3rd eyelid tissue came from the Left or Right eye. Circle if
the lymphoid tissue was Seen or Unseen

VS FORM 5-29A
DEC 2011


File Typeapplication/pdf
File TitleInForms - vs5-29a.wpf
AuthorKHBROWN
File Modified2011-12-13
File Created2007-11-19

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