VS 10-4 Specimen Submission

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 are 0579-0090, 0579-0101, 0579-0146, 0579-0189, 0579-0212, and 0579-0324. The time required to complete this
information collection is estimated to average .16 hours to 1 hour 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
0579-0090, 0579-0101,
0579-0146, 0579-0189,
0579-0212, and 0579-0324

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
NATIONAL VETERINARY SERVICES LABORATORIES
P.O. BOX 844, 1920 DAYTON AVENUE, AMES, IA 50010
515-337-7514
INSTRUCTIONS: Use a separate form for each species and each owner/broker. See “Instructions for Completing VS Form 10-4” for definitions.
1. SUBMITTER NAME (Including Business Name)
2. NVSL SUBMITTER ID
3. NAME OF OWNER

PAGE

SPECIMEN SUBMISSION

EMAIL ADDRESS

OF

Check if wildlife (No owner)

OWNER CITY

PHONE NUMBER
MAILING ADDRESS (Street, City, State, ZIP Code)

STATE/COUNTRY

4. LOCATION OF ANIMALS
PREMISES ID

FAX NUMBER

COUNTY

STATE/COUNTRY

5. PAYMENT METHOD
USER FEE ACCOUNT NO.

CHECK/MONEY ORDER
(Enclosed, payable to USDA in U.S. dollars)

6. HERD/FLOCK SIZE

Credit Card Number:
Expiration Date:
10. COLLECTED BY

9. EXAMINATIONS REQUESTED

7. NUMBER IN HERD/FLOCK AFFECTED

11. DATE COLLECTED

8. NUMBER IN HERD/FLOCK DEAD

12. AUTHORIZED BY

13. PURPOSE OF SUBMISSION (See instructions for definitions)

14. COUNTRY OF ORIGIN

Interstate Movement

Import

TB

Reagent Evaluation

Export

FAD/EP Diagnostic

General Diagnostic

NVSL Intralab

Surveillance

Developmental Research

Pre-Import
16. PRESERVATION
None
Ice Pack

Dry Ice

Formalin

Borax

Alcohol

15. REFERRAL NUMBER

Other (Specify)

17. SPECIMENS SUBMITTED (“X” applicable item(s))

18. TOTAL NUMBER OF
SPECIMENS SUBMITTED

Blood

Feces

Parasite

Serum

Tissue (Specify)

Whole Animal

Culture

Feed

Plant

Soil

Urine

Fetus

Extract

Milk

Semen

Swab (Specify)

Water

DNA/RNA

Other (Specify)

19. SPECIES OR SOURCE (“X” ONLY one)

20. NUMBER OF ANIMALS
SAMPLED

Cattle

Goat

Chicken

Bison

Fish

Swine

Horse

Turkey

Deer (Specify)

Environment

Sheep

Donkey
Other bird (Specify)
Elk
21. IDENTIFICATION (See instructions <250 samples per form)
Sample ID
Animal ID
Breed
Age

Other (Specify)

Reagent
Sex

Sample ID

IDENTIFICATION
Animal ID
Breed

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

NVSL USE ONLY

23. SIGNATURE OF SUBMITTER AND DATE

CONDITION
VS FORM 10-4
AUG 2009

PRIORITY

NVSL USE ONLY
DISTRIBUTION

RECEIVED BY

Age

Sex

VS FORM 10-4 INSTRUCTIONS
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.
If including more than one page, include the page number of total pages
submitted (e.g., 1 of 3).
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. NVSL SUBMITTER ID
For more efficient service, repeat submitters are encouraged to include their
NVSL Submitter ID. If you do not know your ID, contact the NVSL at
515-337-7514.
3. OWNER INFORMATION
“REQUIRED”
Enter the complete name of the animal 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. For wildlife, check
the box to indicate there is no owner.
4. LOCATION OF THE ANIMALS
“REQUIRED”
Include National Animal Identification System (NAIS) premises ID, if available.
Also, specify the county, parish, or other designated location of the animals and
the two-letter State abbreviation.
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. HERD/FLOCK SIZE
Enter the total number of animals in the herd/flock.
7. NO. IN HERD/FLOCK AFFECTED
Enter the total number of animals in direct contact with suspect animal or
showing clinical signs.

13. PURPOSE OF SUBMISSION
“REQUIRED”
Definitions of Diagnostic Case Categories are as follows:
Interstate Movement – Tests conducted for the purpose of qualifying live animals
or poultry for interstate movement.
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.
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.
FAD/EP Diagnostic – 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, follow
instructions in Block 12 for authorization to submit a FAD specimen.
Surveillance – Tests conducted for monitoring for a specific disease, for a
specific insect or insect vector, or for analyzing specific products that are used in
treating animals or poultry or for decontamination of animal poultry facilities.
TB – Tests conducted for diagnosing Tuberculosis.
General Diagnostic Case – Tests conducted for the purpose of diagnosing or
confirming a domestic disease, and/or the analysis of environmental products
that may be contributing to an existing disease condition. Use this purpose when
the purposes listed above do not apply.
Developmental/Research – Tests conducted for the purpose of supporting a
developmental or research project conducted by staff or field personnel of VS or
by other laboratories, institutions, or agencies.
Reagent Evaluation – Tests conducted for the purpose of evaluating a reagent
produced by other laboratories, institutions, or agencies.
NVSL Intralab – Tests conducted for another laboratory of the NVSL.
14. COUNTRY OF ORIGIN/DESTINATION
For import or pre-import cases, enter the country in which the animals last
resided. For export cases, enter the country to which the animals will be
shipped.
15. REFERRAL NUMBER
This number is typically assigned by the submitter and is used for the submitter’s
own reference. In FAD cases, enter the investigation control number described
in the instructions for Block 12.
16. PRESERVATION
Check all blocks that apply.
17. SPECIMENS SUBMITTED
Check all blocks that apply.

“REQUIRED”

18. 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.

8. NO. IN HERD/FLOCK DEAD
Enter the total number of animals from this herd/flock that are dead.

19. SPECIES OR SOURCE
“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.

9. EXAMINATIONS REQUESTED
“REQUIRED”
For disease programs, it is necessary only to enter the program name
(e.g., CWD, Scrapie, or BSE). If the test is not for a disease program, specify the
disease and the desired test.

20. NUMBER OF ANIMALS SAMPLED
Enter the total number of animals sampled.

10. COLLECTED BY
Enter the complete name of the person collecting the specimen(s).
11. DATE COLLECTED
Enter the date on which specimens were collected. Use the format
DD/MM/YYYY.
12. AUTHORIZED BY
Enter the name of the person authorizing the submission of this sample.
Normally, this is the Area Veterinarian in Charge (AVIC) in your State.
Authorization is assumed for regulatory veterinarians making routine program
specimen submissions. See
http://www.aphis.usda.gov/animal_health/area_offices/ to locate the AVIC in your
local area.
If an exotic (foreign) disease is suspected, contact the AVIC and the Emergency
Programs staff to obtain authorization to submit samples for FAD testing and an
investigation control number that must be included with the submission. DO
NOT ship any such specimens until approval is received and a control number is
assigned. The receipt of an unauthorized shipment of specimens containing
exotic disease agents can cause substantial disruption of work at the laboratory
and result in possible fines for the submitter.

VS Form 10-4 (Reverse)

21. 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
elsewhere on the form.
•
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.