Specimen Submission

Status: Original and derived artifacts are available for this document.

Download: pdf

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 information. Send comments regarding this burden statement or any other aspect of this information collection, including suggestions for reducing this
burden, to [email protected].

OMB Approved
0579-0090
Exp. Date XX/XXXX

PAGE

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
NATIONAL VETERINARY SERVICES LABORATORIES
1920 DAYTON AVENUE, AMES, IA 50010
515-337-7266
INSTRUCTIONS: Use a separate form for each owner/broker. See “Instructions for Completing VS Form 10-4” for definitions.
1. SUBMITTER INFORMATION
2. OWNER INFORMATION
NAME (Including Business Name)
WILDLIFE

SPECIMEN SUBMISSION

YES
EMAIL ADDRESS (For results reports and bill)
MAILING ADDRESS (Street, City, State, ZIP Code)

OF

3. LOCATION OF ANIMALS
COUNTY & STATE or COUNTRY

NO

OWNER NAME

PREMISES ID

PHONE NUMBER

OWNER CITY

4. HERD/FLOCK INFORMATION
TOTAL
NUMBER
NUMBER
NUMBER
SICK
DEAD

FAX NUMBER

STATE/COUNTRY

5. PAYMENT METHOD (Check one, enter needed information)
User Fee Account
Credit Card (Incl. number, expiration date)

6. REFERRAL NUMBER

Check/Money Order (Enclosed, payable to USDA in U.S. dollars)
7. PURPOSE OF SUBMISSION (“X” ONLY one. See instructions for definitions)

8. FAD INVESTIGATION NUMBER

Sick Animal

Animal Import/Export

Reagent Evaluation

FAD/EP Diagnostic

Pre-Import to U.S.

Agent Characterization

Confirmation

Animal Product Import/Export

Research

Environmental Monitoring

Interstate Movement

Healthy Animal (Not otherwise specified)

9. COUNTRY OF ORIGIN
10. COUNTRY OF DESTINATION

11. SPECIES OR SOURCE OF SAMPLES (“X” all applicable items)

12. COLLECTED BY

Cattle

Horse

Chicken

Environment

Sheep

Donkey

Turkey

Reagent

Goat

Elk

Other bird (Specify)

Isolate

Swine

Bison

Fish (Specify)

Elephant

Deer (Specify)

Crustacean (Specify)

Other (Specify)

13. DATE COLLECTED
14. TOTAL NUMBER OF SAMPLES
SUBMITTED
15. NUMBER OF ANIMALS SAMPLED

16. SAMPLE TYPES SUBMITTED (“X” all applicable items)
Blood

Swab (Specify)

Tissue (Specify)

Feces

Culture

Soil

Serum

Semen

Fetus

Milk

Parasite

Plant

DNA/RNA

Urine

Whole Animal

Water

Trunk Wash

Feed

Other (Specify)

17. EXAMINATIONS REQUESTED

18. SHIPPING PRESERVATION
Ice Pack

Dry Ice

Other (Specify)
None
19. IDENTIFICATION (See instructions <250 samples per form)
Sample ID
Animal ID
Breed
Age
Sex

Sample ID

Animal ID

IDENTIFICATION

Breed

20. ADDITIONAL DATA (History, clinical signs, post mortem findings, remarks, tentative diagnosis, special instructions. Use additional sheets, if necessary).

NVSL USE ONLY

21. SIGNATURE OF SUBMITTER AND DATE

CONDITION

VS FORM 10-4
OCT 2023

PRIORITY

NVSL USE ONLY
DISTRIBUTION

RECEIVED BY

Age

Sex

VS FORM 10-4 INSTRUCTIONS

Submitters are encouraged to utilize the electronic submission portal available
here:
If using the paper form, ALL information must be printed legibly or typed. Use a
separate form for each species and owner. At the minimum, complete all fields
designated in these instructions as required. Contact the Receiving Department
of the laboratory to which you are sending specimens with specific
documentation or shipping questions.

Agent Characterization – Tests conducted to characterize an isolated
microorganism that is not part of program disease confirmation.
Research – Tests conducted for the purpose of supporting a research project
conducted by staff or field personnel of VS or by other laboratories, institutions,
or agencies.
Healthy Animal – Tests conducted on animals with no clinical signs as part of a
surveillance program,

If including more than one page, include the page number of total pages
submitted (e.g., 1 of 3).

8. FAD INVESTIGATION NUMBER
Enter the number provided by the SAHO for authorization to submit samples.
Required for FAD/EP submissions.

1. SUBMITTER CONTACT INFORMATION
“REQUIRED”
Enter the submitter’s business name/affiliation; the name of the individual
submitter is optional if test results are returned to a general business fax, email,
or mailing address. Enter a fax number or email address to which APHIS can
return test results. Multiple email addresses are permissible. Specify if there is a
preferred method of report delivery; email will be used if no preference is stated.
Provide a complete mailing address. If fax or email is not available, test reports
can be mailed, but this will delay delivery of results. Repeat submitters are
encouraged to be consistent with the submitter contact information that is
provided, 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 22, Additional Data.
2. OWNER INFORMATION
“REQUIRED”
Check yes for wildlife only if free ranging and there is no owner. All other
animals, enter the complete name of the owner, the city and the two-letter
abbreviation of the State in which the owner resides. Ensure the animal owner is
identified here and not the property manager or veterinarian.
3. LOCATION OF THE ANIMALS
“REQUIRED”
Specify the county, parish, or other designated location of the animals and the
two-letter State abbreviation. Include the premises ID if available.
4. HERD/FLOCK INFORMATION: Enter the total number of animals in the
herd/flock. Enter the total number of animals showing clinical signs. Enter the
total number of animals from this herd/flock that are dead.
5. PAYMENT METHOD
“REQUIRED FOR BILLABLE CASES”
Check the appropriate payment method. If payment is by user account or credit
card, enter the account number. Enter the expiration month and year when using
a credit card. Refer to the User Fees/Payment Options and the Catalog of
Services/Fees, both located at
www.aphis.usda.gov/animal_health/lab_info_services/diagnos_tests.shtml, for
specific test fees and a list of accepted credit cards. DO NOT SEND CASH.
6. REFERAL NUMBER
This number is typically assigned by the submitter and is used for the submitter’s
own reference.
7. PURPOSE OF SUBMISSION
“REQUIRED”
Definitions of Diagnostic Case Categories are as follows:
Sick Animal – Tests conducted when animals have clinical signs of a disease.
FAD/EP – Foreign animal disease / emergency programs. Tests conducted for
the purpose of diagnosing or confirming a foreign disease, or for the eradication
of a foreign disease that has gained entrance into the U.S. If a foreign animal
disease is suspected, contact the state animal health official (SAHO) to obtain an
FAD investigation number which is required for FAD/EP submissions.
Confirmation – Tests conducted on samples following non-negative, suspicious,
or inconclusive test results.
Environmental Monitoring – Tests conducted on samples from the animal’s
environment and not from the animal itself.
Import/Export – Import: Tests conducted for the same purpose as pre-import
except that the animals or products are currently located at a U.S. import center.
Export: Tests conducted for the purpose of qualifying animals or poultry,
including wild animals and birds, or animal or poultry products for export from the
U.S. to a foreign country.
Pre-Import – Tests conducted for the purpose of qualifying animals or poultry,
including wild animals and birds, or animal or poultry products for import into the
U.S. Select this purpose when the animals or products have not yet been moved
into the U.S.
Animal Product Import/Export – Tests conducted on the animal for purposes of
qualifying their germplasm or other product for import into or export from the US.
Interstate Movement – Tests conducted for the purpose of qualifying live animals
or poultry for interstate movement.
Reagent Evaluation – Tests conducted for the purpose of evaluating a reagent
produced by other laboratories, institutions, or agencies.

VS Form 10-4 (Reverse)

9. COUNTRY OF ORIGIN
For import/export or pre-import cases, enter the country in which the animals will
be coming from or have originated.
10. COUNTRY OF DESTINATION
For import/export or pre-import cases, enter the country in which the animals will
be or have shipped.
11. SPECIES OR SOURCE OF SAMPLES
“REQUIRED”
Check only one block. If specimens are from different species or sources, use a
separate VS Form 10-4 for each source. Reminder: Enter the animal BREED in
Block 21.
12. COLLECTED BY
Enter the complete name of the person collecting the specimen(s).
13. DATE COLLECTED
Enter the date on which specimens were collected. Use the format
DD/MM/YYYY.
14. TOTAL NUMBER OF SPECIMENS SUBMITTED
Enter the total number of specimens submitted. Specimens in one container are
counted as one sample. Please limit to <250 samples per submission.
15. NUMBER OF ANIMALS SAMPLED
Enter the total number of animals sampled.
16. SAMPLE TYPES SUBMITTED
“REQUIRED”
Check all blocks that apply. Be sure specimens are clearly labeled with the
sample type if multiple sample types are submitted.
17. EXAMINATIONS REQUESTED
“REQUIRED”
For disease programs, it is necessary only to enter the program name
(e.g., CWD, Scrapie, or BSE). If the submission is not for a disease program,
specify the disease and the desired tests.
18. PRESERVATION
Check all blocks that apply.
19. IDENTIFICATION
“REQUIRED”
Sample ID – Identify samples with consecutive numbers. Ensure the sample
identification number on this form matches the sample identification
number placed on the specimen container.
Animal ID – Record the animal’s national identification tag number adjacent to
the appropriate sample number. If there is no national animal identification
number, record the most appropriate identification number (or name).
NOTE: Laboratory results will be reported by animal identification number.
Breed – Enter the animal breed (e.g., Holstein, Angus).
Age – Indicate the approximate age in years (y), months (m), weeks (w), or
days (d).
Sex – Indicate the sex, male (M) or female (F), for each animal.
22. ADDITIONAL DATA
Enter all pertinent information about the animals and premises that can assist the
lab in making a diagnosis.
•
Provide detail on tissue specimens you are including (e.g., lymph nodes,
obex, brain).
•
Specify clinical signs (e.g., weight loss, hair missing).
•
If meat is being retained pending specimen results, enter RETAINED.
•
Add related case submission numbers to assist in trace activities.
•
Include any information that did not fit into its designated space
•
Include any special (non-standard) instructions for test report delivery.
23. SIGNATURE OF SUBMITTER AND DATE
The individual submitting the specimen(s) must sign and date the form