VS 10-3 Request for Salmonella Serotyping

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 displays a valid OMB control number. The valid OMB control number for this information collection is 0579-0007. The time required to complete this information collection is estimated to average .16 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.							OMB Approved 0579-0007 Exp.: XX/XXXX
This report is required by Regulations (9 CFR Part 145). Failure to report will hinder investigation of disease to determine origin of the infection.
UNITED STATES DEPARTMENT OF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECTION SERVICE NATIONAL VETERINARY SERVICES LABORATORIES AMES, IOWA 50010 REQUEST FOR SALMONELLA SEROTYPING				INSTRUCTIONS: Use a separate request for each flock or herd problem. All cultures from the same flock or herd problem should be on one request. Items 17, 18, 19, 20– to be completed by the NVSL. Submit the original and first copy of this request to the NVSL; keep the last copy for your records.
1. NAME AND MAILING ADDRESS OF HERD/FLOCK OWNER (Include ZIP Code)		2. LAB CODE				3. ACCESSION NO/REFERRAL NO.
		4. SOURCE ANIMAL				5. ORIGINAL NO. IN HERD/FLOCK
		6. NO. IN HERD/FLOCK AFFECTED				7. NO. IN HERD/FLOCK DEAD
8. AGE GROUP (“X” one) Prenatal Newborn Immature Mature Mixed Ages Not Applicable
9. CINICAL ROLE (“X” one) Primary Infection Secondary Infection Monitor Sample Environmental Feeds Research Other
10. BACTERIAL TYPING (“X” one) Salmonella Arizona
11. POULTRY SPECIMENS ONLY
A. NAME AND MAILING ADDRESS OF HATCHERY (Include ZIP Code)		B. SPECIMEN SOURCE (“X’ one) Primary Breeding Flock Commercial Flock Multiplier Breeding Flock Other
		C. TYPE (“X” one) Egg Type Chicken Meat Type Chicken			Turkeys Waterfowl, Exhibition Poultry, and Game Birds
12. SPECIMEN CULTURED	13. CULTURE NO.		14. O GROUP			18. SEROTYPE
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
15. SUBMITTED BY (Name and Title)	16. TELEPHONE NUMBER		17. DATE SUBMITTED			18. SEROTYPED BY
19. ACCESSION NO.						20. RECEIVED BY

VS FORM 10-3 Previous editions may be used

JUNE 2009