VS 10-11 Equine Infectious Anemia Laboratory Test

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of information.
UNITED STATES DEPARTMENT OF AGRICULTURE
FORM SERIAL NUMBER
ANIMAL AND PLANT HEALTH INSPECTION SERVICE

OMB Approved
0579-0127

OFFICIAL VS 10-11 EQUINE INFECTIOUS ANEMIA TEST FORM

COMPLETION OF FIELDS #2 – #24 IS REQUIRED.
1. ACCESSION NUMBER (For laboratory use only)
2. DATE BLOOD DRAWN

IF NONE: LINE THROUGH BOX FULLY OR WRITE “NONE”.
3. TEST REQUESTED BY VETERINARIAN
ELISA

4. REASON FOR TESTING
Interstate
Movement

Within State
Use/Annual

Change
Ownership/Sale

International
Import/Export

AGID

Illness/Clinical
Suspect

Investigation/Exposure

5. NAME AND MAILING ADDRESS OF OWNER
5a. NAME

7. CURRENT HOME PREMISES OF EQUINE (ranch, farm, stable, or market)
7a. NAME

5b. MAILING ADDRESS

7b. PHYSICAL/STREET ADDRESS

5c. CITY

5d. STATE

5e. ZIP CODE

7c. CITY

7d. STATE

6. COUNTY OF CURRENT HOME PREMISES OF EQUINE

5f. OWNER TELEPHONE NUMBER

7e. ZIP CODE

7f. PREMISES TELEPHONE NUMBER

I CERTIFY I AM A CATEGORY II, FEDERALLY ACCREDITED, VETERINARIAN, AUTHORIZED IN THE STATE WHERE THE SAMPLE WAS OBTAINED, BY ME, FROM THE ANIMAL DESCRIBED BELOW.
8a. VETERINARIAN NAME
8b. NATIONAL ACCREDITATION NUMBER
8c. STATE IN WHICH BLOOD SAMPLE WAS OBTAINED
8d. VETERINARIAN SIGNATURE

8e. SIGNATURE DATE

8f. MAILING ADDRESS OF VETERINARIAN
9. TUBE #

8g. CITY

10. NAME OF ANIMAL

8h. STATE
11. COLOR

8I. ZIP CODE

8j. TELEPHONE NUMBER

12. BREED OF HORSE (or Species of Equid)

13. SEX
MALE INTACT
FEMALE INTACT

14. AGE OR DOB

15. TAG #

16. TATTOO #

17. MICROCHIP #

18. BREED REGISTRATION #

GELDING
FEMALE SPAYED

SHOW ALL PERMANENT WHITE MARKINGS, BRANDS, TATTOOS and SCARS. MARK WHORLS WITH AN “X”

5

5
4

4
3

1

REQUIRED:

2

3
2

3

3

1

2
1 - Coronet, 2 - Pastern, 3 - Fetlock, 4 - Carpus, 5 - Hock

2

NARRATIVE DESCRIPTION OF PERMANENT WHITE MARKINGS, BRANDS, TATTOOS, SCARS, AND WHORLS. (If none: line through box fully or write “none”)

19. HEAD

20. NECK AND BODY (include coat color patterns if any)

21. LEFT FORELIMB

22. RIGHT FORELIMB

23. LEFT HINDLIMB

24. RIGHT HINDLIMB
FOR LABORATORY USE ONLY

25. EIA LABORATORY NAME

26. DATE SAMPLE RECEIVED

27. DATE RESULTS REPORTED

28. OFFICIAL TEST RESULT
NEGATIVE

29. TEST TYPE USED
POSITIVE

AGID

ELISA

30. LABORATORY REMARKS
25a. CITY

25b. STATE

31. SIGNATURE OF NVSL - APPROVED EIA TECHNICIAN

32. INTERIM RESULT REFERRED FOR CONFIRMATION

FALSIFICATION OF THIS FORM OR KNOWINGLY USING A FALSIFIED FORM IS A CRIMINAL OFFENSE AND MAY RESULT IN A FINE OF NOT MORE THAN $10,000 OR IMPRISONMENT
FOR NOT MORE THAN 5 YEARS OR BOTH (18 U.S.C. SECTION 1001).
VS FORM 10-11
PART. 1 - VETERINARIAN/SUBMITTER
MAY 2023

VS Form 10-11 Instructions Sheet

(Completion of Fields 2 - 24 is required; if none, line through box fully or write “none”)
Field 1: Accession Number Leave blank.
Field 2: Date Blood Drawn
Indicate the date the veterinarian obtained the sample from
the animal. This is the official test date.
Field 3: Test Requested by Veterinarian
The veterinarian determines which test should be run by the
laboratory - based on the reason for the testing.
Field 4: Reason for Testing
If more than one option applies, mark the most compelling
reason for performing the test.
Interstate Movement = movement between States.
Within State Use/Annual = movement within a State
(intrastate), shows/events, or any annual or routine testing.
Change Ownership/Sale = includes tests run for private
sales, markets or auctions whether required by state law or
otherwise.
International Import/Export = international movement into or
out of the USA.

Field 8e: Signature Date The date the veterinarian signed the form.
Fields 8f, g, h, I, j: Mailing address & Phone Number of Veterinarian
Mailing address and phone number of veterinarian.
Field 9: Tube Number (#) If applicable, per accredited veterinarian.
Field 10: Name of Animal
If the animal does not have a name enter NONE however, a
unique identifying number associated with the animal will be
required in Field 16, 17 or 18.
Field 11: Color Enter coat or hair color(s).
Field 12: Breed of Horse (or species of equid)
Enter the horse’s breed(s). If equid is not a horse enter the
species. Ex: donkey, mule, hinny or zebra.
Field 13: Sex Check the box to indicate sex.
Field 14: Age or DOB
Record the animal’s age (XX) in years (Y); use months (M) if
less than one year (Example: 01Y or 12M) or indicate the date
of birth: MM/DD/YYYY.

Illness/Clinical Suspect = diagnostic testing of sick animals.

Field 15: Tag Number (#) any tag number used for ID. If none enter
NONE.

Investigation/Exposure = official investigations by authorities.

Field 16: Tattoo Number (#) Enter tattoo number. If none enter NONE.

Field(s) 5: Name & Mailing Address of Owner
May be a market or auction. This section was designed for
use in a window envelope. For best results you should use
ALL CAPS, dark ink, print clearly and follow USPS guidance.
Field 6: County of Current Home Premises of Equine
The county of the current home premises equine residence in
Field 7.
Field(s) 7: Current Home Premises of Equine
Physical address of the current home premises or residence
of the animal. This includes farms, stables or racetracks where the animal normally lives. It may include a market
location if the home premises is unknown. It should NOT
include a temporary location such as a veterinary clinic. DO
NOT use a Post Office Box.
Field 8a: Veterinarian Name
Name of veterinarian who drew sample. DO NOT enter a
practice name.
Field 8b: Veterinarian National Accreditation Number
National Veterinary Accreditation Number of Cat II
accredited veterinarian who drew the blood sample.
Field 8c: State in Which the Blood Sample Was Obtained
Use the 2 letter code for the State in which the blood sample
was obtained.
Field 8d: Veterinarian Signature
Signature of the accredited veterinarian who drew the blood
sample.
VS FORM 10-11
(Reverse)

Field 17: Microchip Number (#)
Enter the microchip number or NONE DETECTED.
Field 18: Breed Registration Number (#) enter number, NONE or
UNKNOWN
Silhouette/Line drawing
Instructions: This section, while not required, complements the
required narrative descriptions in Fields 19 – 24. Show, draw
or otherwise represent all permanent white markings, brands,
tattoos, and scars. Mark whorls with an X. The animal should
be uniquely identified. Non-descript animals require greater
detail; use whorls and scars to properly identify the animal.
Brands should be drawn.
Fields 19 - 24: Head, Neck & Body, Left Forelimb, Right Forelimb, Left
Hindlimb, Right Hindlimb.
The narrative description is required; indicate all permanent
white markings, brands, tattoos, scars, & whorls. Blank fields
are not acceptable - if none line through box fully or enter
“NONE”. The animal should be uniquely identified. Nondescript animals require greater detail; use whorls and scars to
properly identify. For the head suggested nomenclature
includes any combination of star, strip, snip, lip, chin, blaze,
bald; modified by “connected” if applicable. For limb markings
describe the most proximal extent of the white area. Suggested
nomenclature includes none, heel, coronet, pastern, fetlock,
cannon, carpus/hock, above carpus/hock.
Fields 25 - 32: For Laboratory Use Only: Leave blank

PASTERN

FETLOCK

BELOW CARPUS

VS FORM 10-11
DEC 2020

CORONET