Form PPQ 10 PPQ 10 PPQ Pest Reporting 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 0579-0311. The time
required to complete this information collection is estimated to average 5 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.

U.S. DEPARTMENT OF AGRICULTURE

OMB APPROVED
0579–0311

Plant Protection and Quarantine
Pest Reporting Form

ANIMAL AND PLANT HEALTH
INSPECTION SERVICE (APHIS)

CONTACT INFORMATION

1. FIRST NAME

2. LAST NAME

3. PHONE NUMBER

4. EMAIL

5. CITY

6. COUNTY

7. STATE

8. ZIP CODE

LOCATION AND DATE OF SIGHTING

9. STREET ADDRESS
10. CITY

11. COUNTY

12. STATE

13. ZIP CODE

14. DATE OF SIGHTING

15. DESCRIPTION OF SIGHTING LOCATION (i.e., nearby cross streets, physical landmarks, other features to help pinpoint the location of the suspected
pest or disease), AND GPS COORDINATES OF SIGHTING (optional)

LOCATION AND DATE OF SEARCH

16. STREET ADDRESS
17. CITY

18. COUNTY

19. STATE

20. ZIP CODE

21. DATE OF SEARCH

22. DESCRIPTION OF SEARCH LOCATION (i.e., homeowner’s property, public park, trees along street, etc.)

23. TYPES OF PLANT(S) OR TREE(S) INSPECTED, IF KNOWN

24. NUMBER OF PLANT(S) OR TREE(S) INSPECTED

SIGNS OR SYMPTOMS OF PEST OR DISEASE DAMAGE OBSERVED

25. DID YOU OBSERVE ANY SIGNS OR SYMPTOMS OF PEST OR DISEASE DAMAGE?

YES

NO

YES

NO

26. DESCRIPTION OF DAMAGE OBSERVED

27. UPLOAD PHOTO (submit a photo of what you observed)

28. DID YOU COLLECT A SPECIMEN?

If you would like to report a possible sighting of a plant pest or disease, please complete this form and send it to the USDA APHIS State Plant Health
Director in your State. For a complete contact list, please visit: http://www.aphis.usda.gov/services/report_pest_disease/report_pest_disease.shtml.
PPQ Form 10
MAR 2013