Continuation Sheet for Specimen Submission

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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 numbers for this information collection IS 0579-0090. The time required to complete this information collection is estimated to average 15 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
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UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES

OMB APPROVED
0579-0090
Exp. Date XX/XXXX

PAGE:

CONTINUATION SHEET FOR SPECIMEN SUBMISSION

OF

INSTRUCTIONS: Use this form only as a continuation of information on VS Form 10-4. See instructions for completing VS Form 10-4.
15. REFERRAL NUMBER
3. NAME OF OWNER/BROKER
Check if wildlife (No owner)

OWNER CITY

Sample ID

VS FORM 10-4A
AUG 2009

OWNER STATE/COUNTRY

21. IDENTIFICATION (See instructions)
Animal ID
Breed

Age

Sex

Sample ID

IDENTIFICATION
Animal ID

Breed

Age

Sex

INSTRUCTIONS FOR VS FORM 10-4A
PAGE
Enter the number for this page out of the total number of pages submitted (e.g., 2 of 3).
NAME OF OWNER/BROKER
Enter the complete name of the animal owner from VS Form 10-4, block 3.
REFERRAL NUMBER
Enter the referral number from VS Form 10-4, block 15.
IDENTIFICATION
Continue the specimen numbering sequence started on VS 10-4, block 21. Enter the National Animal ID, breed, age, and sex of each animal sampled. If more than 48
specimens are submitted, use additional VS Form 10-4A as required. Please limit to <250 specimens per VS Form 10-4.