VS 17-146A BSE Surviellance Submission Form Continuation Sheet

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.

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

BSE SURVEILLANCE SUBMISSION
FORM
CONTINUATION SHEET

PAGE

OMB Approved
0579-0409

I
of

1. BSE REFERRAL NUMBER

2. SAMPLE INFORMATION
17

26

BSE Sample ID

18

35

BSE Sample ID

27

BSE Sample ID

36

BSE Sample ID

28

19

20

21

22

23

I

24

I

VS FORM 17-146A
FEB 2014

BSE Sample ID

50

BSE Sample ID

42

3. ADDITIONAL DATA (attach additional page(s), if needed)

4. SIGNATURE OF SUBMITTER

49

41

BSE Sample ID

BSE Sample ID

BSE Sample ID

BSE Sample ID

33

BSE Sample ID

48

40

32

BSE Sample ID

BSE Sample ID

BSE Sample ID

BSE Sample ID

47

39

31

BSE Sample ID

BSE Sample ID

BSE Sample ID

BSE Sample ID

46

38

30

BSE Sample ID

BSE Sample ID

BSE Sample ID

BSE Sample ID

45

37

29

BSE Sample ID

BSE Sample ID

BSE Sample ID

BSE Sample ID

BSE Sample ID

44

BSE Sample ID

BSE Sample ID

I

51

BSE Sample ID

BSE Sample ID

Accession Number

I

VS FORM 17-146A INSTRUCTIONS
The BSE Surveillance Submission Form (VS 17-146) has space to attach identification numbers for 20 animals. If additional animals are
sampled, submit VS 17-146A to list additional animals. VS Form 17-146A should not be submitted without an accompanying VS 17-146 and
the appropriate number of forms VS 17-131 for each animal listed.

PAGE
Enter the number for this page out of the total number of pages submitted (e.g., 2 of 3).
1. BSE REFERRAL NUMBER
The number must correspond to the number listed on the related VS Form 17-146. See instructions for VS 17-146 for details on preferred numbering
format.
2. SAMPLE INFORMATION
Place barcodes for up to 32 additional animals in the spaces provided. See instructions for VS 17-146 regarding barcode availability and distribution.
3. ADDITIONAL DATA
Use this block to provide other pertinent information not captured elsewhere on VS 17-146 or VS 17-131.
4. SIGNATURE OF SUBMITTER
The submitter must sign each page of the form.

Accession Number block is reserved for use by the testing laboratory.