On-Farm Worksheet

RED WITH ASTERICK
INDICATES REQUIRED FIELD

ON-FARM WORKSHEET

Page 1 of

*Owner Name (First/Last):

*Collector’s Name:

*Name of DSE:

*Address:

*Address:

*Address:

*City/State/Zip code:

*City/State/Zip code:

*City/State/Zip code:

Phone Number:

*Phone Number:

*Phone Number:

Email:

Email:

Email:

*Collection/Sampling Date:

*Animal Status: Live / Dead (circle one)

Contact Name:

*Reason for Test:

Number of Animals in Flock

Address:

*Flock ID:

*Total Number of Samples

City/State/Zip code:

*Flock Status :

Test of All Eligible Animals: Yes or No

Phone Number:

ID Value

ID Type

Record all IDs.
Indicate type in
next column

SFCP
Flock
Serial
(metal/
plastic)
Owner
RFID
Tattoo
Other

Sample #
(1 to n)

UPC Barcode

Species

Sheep Goat

Use one barcode number for each
animal tested.

Breed

Refer to
Breed
Code List

Face
Color
(Sheep)

Blk
Wht
Mot
Red
Hair
Gry/brn
Other

Type
(Goats)

Addition
Type

Designation
Sex

Age

Comments

Clinical signs, history, etc.
Dairy
Fiber
Meat
Multi

Natural
Purchased

F
M
MC
NS

Positive
Mos. or Suspect
Yrs. /
Exposed
Est. or Miss exp
Rec.
Less signs
Non clin

Item

Description/Comments/List of Values (LOV)

Collected by:

Person who collected samples for submission. Could be accredited veterinarian or pathologist at
diagnostic lab. If unknown who collected samples, enter name of submitter, person whose name is in
block 1 of the VS 10-4.

Designated Scrapie
Epidemiologist

State or Federal DSE. If DSE is unknown at the time of collection, enter UNKNOWN for all required
fields in this block. Information can be entered/edited when submission is created in VSLS.

Reason for Test

LOV: Exposed, High-risk trace to flock, Infected or Source RSSS positive, Imported, Missing exposed
ewe, Infected or source Not RSSS, Other, Owner Request, Positive, Flock Recertification, Retest,
Surveillance, Suspected, Non clinical

Flock Status

LOV: SFCP, Exposed, Infected, Source, Investigation, Other

Animal Status

Necropsy or Live

# of Animals in Flock

While not a required field, adds helpful information about the flock.

Total # of Samples

Number of samples in this submission

Tested All Eligible Animals:
Yes or No

Response is based on activity or investigation. For example, if you plan to test all the animals in Pen 1
today and all the animals in Pen 2 next week, you would respond "No." In most cases, select "Yes."

Contacts

Contact information for individual other than owner or person submitting the animal (veterinarian)

Remarks

Include any additional relevant information.

Breed

Refer to breed/breed code lists

Face color: Sheep

LOV: Black, White, Mottled, Red, Hair sheep, Gray or mouse brown, Other--specify in remarks, or Not
Specified

Type: Goats

LOV: Dairy, Fiber, Meat, or Multipurpose

Addition Type

Natual addition or purchased

Sex

LOV: Male, Female, Male Castrated and Not Specified

Age

Write down actual (recorded) age or estimated in months or years

Designation

Postive, Suspect, Exposed, Missing ewe, no designation – less specific signs, no designation – non-clinical

Comments

Clinical signs, history, or any other relevant information