Form 10-11 Equine Infectious Anemia Laboratory Test

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, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection
of information.
UNITED STATES DEPARTMENT OF AGRICULTURE
1. FORM SERIAL NUMBER
ANIMAL AND PLANT HEALTH INSPECTION SERVICE

OMB Approved
0579-0127
Exp.: XX/XXXX

OFFICIAL VS 10-11 EQUINE INFECTIOUS ANEMIA TEST FORM
COMPLETETION OF ALL NUMBERED FIELDS IS REQUIRED FOR SUBMISSION, IF NONE WRITE NONE AND PLEASE TYPE OR PRINT LEGIBLY
2. LABORATORY ACCESSION NUMBER (For laboratory use only)
3. DATE BLOOD DRAWN
4. TEST REQUESTED BY VETERINARIAN
ELISA

AGID

5. REASON FOR TESTING
Within State
Use/Annual

Interstate Movement

Change
Ownership/Sale

International
Import/Export

Illness/Clinical
Suspect

6. EQUINE RESIDENCE AT BLOOD DRAW; (Ranch, Farm, Stable, or Market)

8. NAME AND ADDRESS OF OWNER

6a. NAME

8a. NAME

6b. PHYSICAL/STREET ADDRESS

8b. MAILING ADDRESS

6c. CITY, STATE, ZIP CODE

8c. CITY, STATE, ZIP CODE

7. COUNTY OF EQUINE RESIDENCE AT BLOOD DRAW:

6d. TELEPHONE NUMBER

Investigation/Exposure

8d. TELEPHONE NUMBER

I CERTIFY I AM A CATEGORY II FEDERALLY ACCREDITED VETERINARIAN, AUTHORIZED IN THE STATE WHERE THE SAMPLE WAS OBTAINED, BY ME, FROM THE ANIMAL DESCRIBED BELOW
9. VETERINARIAN SIGNATURE
10. VETERINARIAN NAME
11. NATIONAL ACCREDITATION NUMBER
12. SIGNATURE DATE

10a. PHYSICAL/STREET ADDRESS OF VETERINARIAN

14.
Tag/Tattoo/Brand
Number

13.
Tube Number

10b. CITY, STATE, ZIP CODE

15.
Name of Animal

16.
Color

10c. TELEPHONE NUMBER

17.
Breed of Horse

18.
Age or DOB

(or Species of Equid)

(write M for months)

19.
Sex

M - Male Intact
F - Female Intact
G - Gelding
FS - Female Spayed

20. MICROCHIP, BREED OR REGISTRATION NUMBER

SHOW ALL PERMANENT WHITE MARKINGS, BRANDS, TATTOOS, SCARS & WHORLS (marked with an X)

5

5
4

4
3

1

3

3

3
2

1

2
2

2
1 - Coronet, 2 - Pastern, 3 - Fetlock, 4 - Carpus, 5 - Hock

21. HEAD

REQUIRED: NARRATIVE DESCRIPTION OF PERMANENT WHITE MARKINGS, BRANDS, TATTOOS, SCARS AND WHORLS. (If none write none)
Suggested nomenclature includes Heel, Heels, Coronet(1) Half Pastern, Pastern(2), Fetlock(3), Half Canon, Canon, Carpus/Hock(4/5) above Carpus/Hock
22. NECK AND BODY (include coat color patterns if any)

23. LEFT FORELIMB

24. RIGHT FORELIMB

25. LEFT HINDLIMB

26. RIGHT HINDLIMB

FOR LABORATORY USE ONLY
27. EIA LABORATORY NAME

28. DATE SAMPLE RECEIVED

29. DATE RESULTS REPORTED

30. OFFICIAL TEST RESULT
Negative

31. TEST TYPE USED

Positive

AGID

ELISA

32. LABORATORY REMARKS

27a. CITY

27b. STATE

33. SIGNATURE OF NVSL - APPROVED EIA TECHNICIAN

34. INTERIM RESULT REFERRED FOR CONFIRMATION

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
OCT 2017

PART. 1 - VETERINARIAN/SUBMITTER

VS FORM 10-11 (Reverse)
OCT 2017

VS Form 10-11 Instructions Sheet
(Completion of Blocks 3 - 26 is required)
Blocks 1 - 2: Serial & Accession Numbers Leave blank.

Block 12: Signature Date The date the veterinarian signed the form.

Block 3: Date Blood Drawn

Block 13: Tube Number If applicable, per accredited veterinarian.

Indicate the date the veterinarian obtained the sample from
the animal. This is the official test date.
Block 4: Test Requested by Veterinarian
The veterinarian determines which test should be run by the
laboratory - based on the reason for the testing.
Block 5: Reason for Testing

Block 14: Tag/Tattoo/Brand Number
Enter all tattoo numbers and brand(s) present and any tag
number used for ID. If none enter NONE.
Block 15: Name of Animal
If the animal does not have a name enter NONE however, a
unique identifying number associated with the animal will be
required in Block 14 or 20.

If more than one option applies, mark the most compelling
reason for performing the test at this time.

Block 16: Color Enter coat or hair color(s).

Interstate Movement = movement between States.

Block 17: Breed of Horse

Within State Use/Annual = movement within a State
(intrastate), shows/events, or any annual or routine testing.
Change Ownership/Sale = includes tests run for private
sales, markets or auctions whether required by state law or
otherwise.
International Import/Export = international movement into or
out of the USA.

Enter the horse’s breed(s). If equid is not a horse enter the
species. Ex: donkey, mule, hinny or zebra.
Block 18: Age or DOB
Record the animal’s age (XX) in years (Y); use months (M) if
less than one year (Example: 01Y or 12M), or indicate the
date of birth: MM/DD/YYYY.
Block 19: Sex Use abbreviations in the box to the right; indicate sex.

Illness/Clinical Suspect = diagnostic testing of sick animals.
Block 20: Microchip, Breed or Registration Number
Investigation/Exposure = official investigations by authorities.
Block 6: Equine Residence at Blood Draw
Physical address of the current home premises or residence
of the animal. This includes farms, stables or racetracks where the animal lives at the time the blood is drawn. It may
include a market location if the home address is unknown. It
should NOT include a temporary location such as a
veterinary clinic. DO NOT use a Post Office Box.
Block 7: County of Equine Residence at Blood Draw

Enter the microchip number, and/or breed registration
number or other ID number. If none enter NONE.
Silhouette/Line drawing
Instructions: This section, while not required, complements
the required narrative descriptions in Blocks 21 – 26. Show,
draw or otherwise represent all permanent white markings,
brands, tattoos and scars. Mark whorls with an X. The
animal should be uniquely identified. Non-descript animals
require greater detail; use whorls and scars to properly
identify the animal. Detailed brands can be drawn.

The county of the equine residence in Box 6.
Block 8: Name and Address of Owner
May be a market or auction.
Block 9: Veterinarian Signature
Signature of the accredited veterinarian who drew the blood
sample.
Block 10: Veterinarian Name
Name of veterinarian. DO NOT enter a practice name.
Blocks 10a, b, c.: Veterinarian Street Address, Phone Number
Physical address and phone number of veterinarian.
Block 11: National Accreditation Number
National Veterinary Accreditation Number of Cat II
accredited veterinarian who drew the blood sample.

VS FORM 10-11 (Reverse)
OCT 2017

Blocks 21 – 26: Head, Neck & Body, Left Fore-limb, Right Fore-limb,
Left Hind-limb, Right Hind-limb.
The narrative description is required; indicate all
permanent white markings, brands, tattoos, scars & whorls.
Blank blocks are not acceptable - if none enter NONE. The
animal should be uniquely identified. Non-descript animals
require greater detail; use whorls and scars to properly
identify. For the head suggested nomenclature includes any
combination of star, strip, snip, lip, chin, blaze, bald; modified
by “connected” if applicable. For limb markings describe the
most proximal extent of the white area. Suggested
nomenclature includes none, heel, heels, coronet, half
pastern, pastern, fetlock, half canon, canon, carpus/hock,
above carpus/hock.
Blocks 27 – 34: For Laboratory Use Only: Leave blank.

COPY DESIGNATIONS
PART 1 - VETERINARIAN/SUBMITTER
PART 2 - LABORATORY OFFICE
PART 3 - OWNER
PART 4 - VETERINARY SERVICES ASSISTANT DIRECTOR
PART 5 - STATE