VS 17-146A BSE Surviellance Submission Form Continuation Sheet

National Veterinary Services Laboratories; Bovine Spongiform Encephalopathy Surveillance Program

VS_17_146a

State

OMB: 0579-0409

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0579-0409 can be found here:

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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 0579-0409. The time required to complete this information
collection is estimated to average .1 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
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
NATIONAL VETERINARY SERVICES LABORATORIES
P.O. BOX 844, 1920 DAYTON AVENUE
AMES, IOWA 50010
515-337-7514

BSE SURVEILLANCE
SUBMISSION FORM
CONTINUATION SHEET

1. PAGE

OMB Approved
0579-0409
EXP.: 10/2016

1. BSE REFERRAL NUMBER
2. SAMPLE INFORMATION
17

BSE Sample ID

VS FORM 17-146A
JAN 2014

BSE Sample ID

3. ADDITIONAL DATA (attach additional page(s), if needed)

4. SIGNATURE OF SUBMITTER

BSE Sample ID

Accession Number

VS FORM 17-146A IINSTRUCTIONS
The BSE Surveillance Submission Form (VS 17-146) has space to attach identification numbers for 20 animals. If additional animals are
sampled, submit VS 17-146A to list additional animals. VS Form 17-146A should not be submitted without an accompanying VS 17-146 and
the appropriate number of forms VS 17-131 for each animal listed.

PAGE
Enter the number for this page out of the total number of pages submitted (e.g., 2 of 3).
1. BSE REFERRAL NUMBER
The number must correspond to the number listed on the related VS Form 17-146. See instructions for VS 17-146 for details on preferred numbering
format.
2. SAMPLE INFORMATION
Place barcodes for up to 32 additional animals in the spaces provided. See instructions for VS 17-146 regarding barcode availability and distribution.
3. ADDITIONAL DATA
Use this block to provide other pertinent information not captured elsewhere on VS 17-146 or VS 17-131.
4. SIGNATURE OF SUBMITTER
The submitter must sign each page of the form.

Accession Number block is reserved for use by the testing laboratory.

File Type	application/pdf
File Title	According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond
Author	smharris
File Modified	2014-04-04
File Created	2014-01-15