Parasite Submission Form

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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 number for this information collection is 0579-0090. The time required to complete this information collection is estimated to average
between .083 and .17 hours 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. Send comments regarding this burden statement or any other aspect of this information collection, including suggestions for reducing this burden,
to [email protected].

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES

PARASITE
SUBMISSION FORM

OMB Approved
0579-0090
Exp.: XX/XXXX

NATIONAL VETERINARY SERVICES LABORATORIES
1920 Dayton Avenue
Ames, IA 50010
Telephone: 515-337-7514

INSTRUCTIONS: Print in pencil or type. Prepare separate form for each species of animal. Form to accompany specimen. Package specimens well to prevent breakage
en route.
1. Submitter’s Name
2. NVSL Submitter ID
17. Specimen ID
18. Date Collected
3. Business’ Name

19. County in which Collected

20. State in which Collected

4. Address

21. Country in which Collected

22. Premises ID

23. Latitude

24. Longitude

5. City

6. State

8. Telephone Number (Include Area Code)

7. ZIP Code
9. FAX Number

25. Host Origin

10. Email

26. Host Species (cow, horse, sheep, dog, etc.)

11. Owner’s Name

27. Where Found on Host (head, ear, flank, back, etc.)

12. City

13. State

15. Collector’s Name

14. ZIP Code

28. Animal ID

16. Port

29. Number of Animals in Lot

30. Number of Animals Infested

31. History or Additional Information

FOR FIELD LABORATORY USE ONLY (Optional)
32. Date Received

33. Date Identified

34. Referral Number

35. Tentative Identification

Identified by:
FOR NATIONAL VETERINARY SERVICES LABORATORIES USE ONLY
36. Case Number

37. Sample Number

38. Date Received

39. NVSL Identification

40. NVSL Accession Number

Identified By:
VS FORM 5-38
SEPT 2009

Date

GUIDELINES AND EXPLANATORY DETAILS FOR VS FORM 5-38: PARASITE SUBMISSION FORM
USDA, APHIS, VS, NATIONAL VETERINARY SERVICES LABORATORIES, AMES IA
INSTRUCTIONS: Print in pencil or type. Form must accompany specimen. Package specimens to prevent leakage en route. Despite best efforts, specimen vials
may break or leak alcohol in transit; when that happens, accompanying forms that were completed in ink may become illegible.
1-10. Submitter Information: If the submitter has an ID assigned previously by NVSL, give the name of the submitter and that ID. For new submitters, or if the ID is not
known, please also give the name of the business, mailing address, email address, and telephone and FAX numbers, to whom the identification report will be sent. Specify if
there is a preferred method of report delivery; email will be used if no preference is stated. If FAX or email is not available, test reports can be mailed but this will delay
delivery of your results. Repeat submitters are encouraged to be consistent with the submitter contact information that they provide, as the NVSL keeps a master record. If
the test report for an individual submission needs to be routed to a non-standard destination, include special instructions in Block 31 (History or additional information).
11-14. Owner Information: Give the name, city, State, and ZIP Code of the owner of the host animal.
15. Collector’s Name: For multiple collectors, additional names may be given in History or additional information (Field 31).
16. Port: Enter the port of entry, if applicable.
17. Specimen ID: The collector may indicate an identifier for a sample, usually denoting samples taken in series (1, 2, 3, etc.). Please also put that number or other
identifier on or in the associated sample container. Also, see instructions for Referral Number (Field 34).
18. Date Collected: Enter the calendar date on which the sample was collected from the host animal.
19-21. County, State, and Country in which specimens were collected: Specify country only for non-USA collection locales.
22-24. Premises ID, Latitude, and Longitude: Give the Premises ID and/or geographical coordinates (if known). List coordinates as decimal degrees when possible (e.g.,
N27.087821 and W92.021484).
25. Host Origin: Indicate the county, State, and country (if not the USA) of origin of the host animal.
26. Host Species (Cow, horse, sheep, dog, etc.): State the host species from which the parasites were collected. Give only one species, be as specific as possible, and
avoid generic terms like “equine”, “avian”, “reptile”, “canine”, “feline”, etc. Use a separate parasite submission form for each host species. If using “deer”, list the kind of deer
(white-tailed, mule, etc.). For convenience, names used as examples may be encircled or underlined.
27. Where Found on Host (head, ear, flank, back, etc.): Indicate one or more anatomical sites where the specimen(s) was/were found. Names used as examples may be
encircled or underlined.
28. Animal ID: Give ear/back tag numbers, animal name, or other information that identifies the host animal.
29. Number of Animals in Lot: Give a count or estimate of the number of individual animals in the group from which the collection was made.
30. Number of Animals Infested: Give a count or estimate of the number of individual animals in the lot that were infested with parasites; this count will be less than or
equal to the number in the lot.
31. History or Additional Information: This field is open-ended, and may be used to include any additional information pertinent to the collection (e.g., locale, history,
quarantine status, additional collectors, etc.), observations on host animal’s condition, or additional details. This field also may be used for notes or requests to NVSL.
Fields 32-35 are for tentative identifications made at a field laboratory.
34. Referral number: Give submitter’s unique identification number assigned to the sample (e.g., foreign animal disease [FAD] investigation number).
Fields 36-40 are for NVSL use only.