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FORM APPROVED - OMB NUMBER 0579 - 0127
UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
SERIAL NO.
1. ACCESSION NUMBER
2. DATE BLOOD
DRAWN
T
EQUINE INFECTIOUS ANEMIA LABORATORY TEST
(VS Memorandum 555.16)
Forms Without Adequate Descriptions Of The Horse And Complete Addresses Including ZIP Codes, Counties, And
Telephone Numbers Will Not Be Processed.
3. REASON FOR TESTING
Market
Change of Ownership
4. GEOGRAPHIC INFORMATION
SYSTEMS (GIS)
Show
First Test
Retest
Export
7. NAME AND ADDRESS OR STABLE/MARKET (Please print or type)
6. TEST TYPE
5. VETERINARY LICENSE OR
ACCREDITATION NO.
ELISA
LAT:
LONG:
ZIP Code
AGID
County
Tel No.
8. NAME AND ADDRESS OF OWNER (Please print or type)
9. NAME AND ADDRESS OF VETERINARIAN (Please print or type)
ZIP Code
ZIP Code
County
Tel No.
County
Tel No.
CERTIFICATION OF FEDERALLY ACCREDITED VETERINARIAN
I certify the specimen submitted with this form was drawn by me from the horse described below on the date indicated above.
11. TYPE OR PRINT SIGNATURE NAME
10. SIGNATURE OF FEDERALLY ACCREDITED VETERINARIAN
12. SIGNATURE DATE
CERTIFICATION OF OWNER OR OWNER'S AGENT
I certify that I have examined this form and, to the best of my knowledge and belief, this form is true, correct, and complete.
13. SIGNATURE OF OWNER OR OWNER'S AGENT
16 .
Tube
No.
17.
Official
Tag
18.
14. TYPE OR PRINT SIGNATURE NAME
19.
Name of Horse
Tattoo/Brand
20.
Color
15. SIGNATURE DATE
22.
Electronic
I.D. No.
21.
Breed
23.
Age or
DOB
24.
Sex
M - Male
F - Female
G - Gelding
SF-Spayed
Female
SHOW ALL SIGNIFICANT MARKINGS, WHORLS, BRANDS, AND SCARS
5
5
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4
3
3
3
3
1
2
2
1
2
2
1 - Coronet, 2 - Pastern, 3 - Fetlock, 4 - Knee, 5 - Hock
NARRATIVE DESCRIPTION AND REMARKS
25. HEAD
26. OTHER MARKS AND BRANDS
27. LEFT FORELIMB
28. RIGHT FORELIMB
29. LEFT HINDLIMB
30. RIGHT HINDLIMB
FOR LABORATORY USE ONLY
31. LABORATORY NAME/CITY/STATE
32. DATE RECEIVED
33. DATE REPORTED OUT
34. TEST RESULTS
Negative
35. SIGNATURE OF TECHNICIAN
Positive
AGID
ELISA
36. REMARKS
Falsification of this form or knowingly using a falsified form is a criminal offense and may result in a fine of not more than $10,000 or
imprisonment for not more than 5 years or both (U.S.C. Section 1001).
VS FORM 10-11 (MARCH 2014)
COPY DESIGNATIONS
PART. 1 - VETERINARIAN/SUBMITTER
PART. 2 - LABORATORY OFFICE
PART. 3 - OWNER
PART. 4 - VETERINARY SERVICES ASSISTANT DISTRICT DIRECTOR
PART. 5 - STATE
EQUINE INFECTIOUS ANEMIA LABORATORY TEST
VS FORM 10-11
(MAY 2003)
USDA - APHIS
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
0579-0127. The time required to complete this information collection is estimated to average .083 hours per response, including the time for
reviewing instructions, search existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information.
VS FORM 10-11
REVERSE
TOP STUB INSTRUCTIONS
USE TYPEWRITER OR PRINT CLEARLY - PRESS HARD - YOU ARE MAKING 5 COPIES
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File Type | application/pdf |
File Title | InForms - vs10-11.wpf |
Author | kastratchko |
File Modified | 2014-03-24 |
File Created | 2008-05-01 |