Form VS 17-146 VS 17-146 BSE Surviellance Submission 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 6 minutes 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.

I

OMB Approved
0579-0409

UNITED STATES DEPARTMENT OF AGRICULTURE
1. BSE Referral Number
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
BSE SURVEILLANCE
NATIONAL VETERINARY SERVICES LABORATORIES
Page
of
P.O. BOX 844, 1920 DAYTON AVENUE
SUBMISSION FORM
AMES, IOWA 50010
515-337-7514
2. SUBMITTED BY
3. COLLECTION SITE
Name (including Business Name)
NVSL Submitter ID
Premises ID (or Lat/Long) or FSIS Plant Number

Email

Name (including Business Name)

Phone

Fax

Street

Street

City

City

State

ZIP Code

State

Phone

Fax

Use separate submission form for each submitter, collector, collection site, and
collection date combination. Attach a separate Bar Code Sticker (if available)
for each sample in the spaces below. Attach a separate BSE Surveillance
Data Collection Form (VS 17-131) for each animal. Sample IDs on this form
match Sample IDs on BSE Surveillance Data Collection Forms.
must

Email

5. COLLECTION SITE TYPE (select only one)

6. COLLECTED BY or √
Name (including Business Name)

Slaughter Plant
Renderer
Other (describe)

Public Health Lab
On Farm

Diagnostic Lab
3D-4D

7. SAMPLE INFORMATION

4. COLLECTION DATE

□

if Same as Submitted by

Street
City

Number of Samples ______
Preservation
Ice Pack

ZIP Code

Other _________________________________

State

Phone

ZIP Code

Fax

Email
1

5
BSE Sample ID

9
BSE Sample ID

13
BSE Sample ID

BSE Sample ID

II
2

6
BSE Sample ID

10
BSE Sample ID

14
BSE Sample ID

BSE Sample ID

II
3

7
BSE Sample ID

11
BSE Sample ID

15
BSE Sample ID

BSE Sample ID

II
4

8
BSE Sample ID

12
BSE Sample ID

16
BSE Sample ID

BSE Sample ID

II
8. Additional Data (attach additional page(s) if needed)

9. Shipping Date

10. Signature of Submitter

11. Destination Lab

12. Shipment Tracking Number

Condition Received

Distribution

VS FORM 17-146
FEB 2014

Accession Number

I

Received by

I

Date Received

VS FORM 17-146 IINSTRUCTIONS

7. SAMPLE INFORMATION

Complete a separate submission form for each submitter,
collector, collection site, and collection date combination. If
including more than one page, include the page number of total
pages submitted (e.g., 1 of 3).
Also complete VS FORM 17-131 (BSE Surveillance Data Collection
Form) for each animal listed on VS 17-146.

Specify the number of samples being submitted and the preservation
method used for transport. For each sample, provide a unique sample
ID barcode in the BSE Sample ID boxes immediately below Block 7.
Barcodes are available in the sample kits or barcodes can be ordered
from the NVSL at [email protected]. In the event that
barcodes are not available at the time of sample collection, contact the
VS Area Office so that barcodes can be assigned for the submission.

1. BSE REFERRAL NUMBER

8. ADDITIONAL DATA

The number must be a unique identifier for the submission that will not
be duplicated in any other BSE surveillance submission. The BSE
Referral Number is used to associate the BSE Surveillance
Submission Form to the BSE Surveillance Data Collection Form in the
database.

Use this block to provide other pertinent information not captured
elsewhere on the form or VS 17-131.

The suggested format for the BSE Referral Number consists of 13 or
14 alphanumeric characters.

9. SHIPPING DATE
Enter the date the samples are shipped to the laboratory. Use the
MM/DD/YYYY format.
10. SIGNATURE OF SUBMITTER

•
•
•
•

First two characters are the 2-letter postal abbreviation for
the State;
Next two to three characters are the collector’s initials (First,
Middle, Last) ;
Next eight characters are the collection date in the
MMDDYYYY format; and
Last character is a letter representing which submission form
of the day it is for the collector (i.e., A=First)

The submitter must sign the form.
11. DESTINATION LAB
Enter the name (or Laboratory ID) of the laboratory where the samples
are being sent for diagnostic testing.
12. SHIPMENT TRACKING NUMBER

Example 1. COSAJ06012006A
Translates to: Colorado – Steven Allen Jones – June 1, 2006 –
first submission of the day.
Example 2. COSAJ06012006B
Translates to: Colorado – Steven Allen Jones – June 1, 2006 second submission by Steven Allen Jones for that day, either
from the same collection site or a different collection site.
2. SUBMITTED BY
Enter requested information for the person submitting the sample to
the laboratory (the submitter). If the samples are being submitted to
the NVSL, and the submitter has a NVSL Submitter ID, provide it.
3. COLLECTION SITE
Enter all the requested data for the collection site. Ensure that the
National Premises Identification Number (if available) or the FSIS
Establishment Number where the sample was collected is entered.
4. COLLECTION DATE
Enter the date the samples were collected. All samples on one form
must be collected on the same day. Use the MM/DD/YYYY format.
5. COLLECTION SITE TYPE
Select the type of facility where the sample was collected.
6. COLLECTED BY
Enter all of the information requested for the person that actually
collected the tissue sample for submission to the testing laboratory. If
the Collector is the same as the Submitter, it is only necessary to
check the indicated box.

Enter the airbill or shipment tracking number for the package(s) being
sent to the diagnostic laboratory.

Conditions/Distribution/Received By/Date Received/ Accession
Number blocks are reserved for use by the testing laboratory.