VS 17-131 BSE Surviellance Data Collection Form

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 6 minutes 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
VETERINARY SERVICES

OMB APPROVED
0579-0409

BSE SURVEILLANCE DATA COLLECTION FORM

***THIS FORM MUST BE USED IN CONJUNCTION WITH VS 17-146 (BSE SURVEILLANCE SUBMISSION FORM). DO NOT SUBMIT ALONE.***

1. PRIMARY REASON FOR SUBMISSION (check the selection with the smallest number that applies)
□ 1. Highly suspicious for BSE
□ 5. Nonambulatory/Disabled/Downer
FSIS, antemortem condemned cattle
clinical signs that may be associated with
□ 2.
□ 6. Other
BSE as noted below
□ 3. Rabies suspect
□ 4. CNS signs
□ 7. Dead
3. INDIVIDUAL DETERMINING PRIMARY REASON (BLOCK 1) AND CLINICAL SIGNS (BLOCK 13) (select one)
□ 1. Veterinarian employed by APHIS
□ 5. Renderer/deadstock hauler/3D-4D
□ 2. Veterinarian employed by FSIS
□ 6. Producer/owner
□ 3. Other Veterinarian
□ 7. Other (describe in Block 10)
□ 4. Other APHIS personnel

2. BSE Referral Number
(must agree with # on VS 17-146)

4. BSE Sample ID

Please use barcode, if availableI

Name (including Business Name)

6. SLAUGHTER SITE OR √ □ if same as Collection Site on VS 17-146
(complete only if slaughtered at State or FSIS-inspected facility)
Premises ID or FSIS Plant Number

Street

Name (including Business Name)

5. OWNER INFORMATION

City

State

ZIP Code

Street

Country (if not USA)

Premises ID or Lat/Long

City

Phone

Fax

Phone

County

Email

Email

7. ANIMAL INFORMATION
a. Animal Breed (if known)
b. Age_______
If breed not known:
□ Beef Breed
□ Dairy Breed

Primary Colors:

e. Country of Origin (only if
KNOWN to be other than USA)

State
Fax

□

Months

□

Years

Age is:

nd

Dentition: 2 Set of Incisors Erupted

f. Official USDA Tag No.

ZIP Code

□
□

Yes
No

□ Estimated
□ Recorded

g. FSIS Condemnation Tag No.

c. Gender
□ Female
□ Male
□ Unknown

d. Neutered
□ Yes
□ No
□ Unknown

h. Back Tag No.

i. Microchip No.

l. Owner Ear Tag No.

m. Other ID No.

Zj. Collection Site Tracking No.

k. Slaughter Tracking No.

8. CLINICAL SIGNS (select all that apply)
□ Abnormal head carriage
□ Head pressing/rubbing
or belligerent
Head shyness
□ Aggressive
□ Hyperesthesia
(sensitivity to light or sounds,
□ Apprehensive or nervous
□
shifting ears)
□ Ataxia (abnormal gait,
uncoordinated)
□ Hesitation at doors, gates, or barriers
□ Blindness
□ Kicking while milking (when did not before)
□ Circling
□ Paralysis
□ Droopy lip or eyelid
□ Tremors or nystagmus
(includes eye movements, head tremors)
□ Excessive bellowing
□ Excessive licking
□ Excitable

Signs marked at left:
over time
□ Worsened
□ Did not worsen
□ Don’t know

→

The animal:
□ Responded to treatment
□ Did not respond
□ Don’t know

→

Other signs observed:
Depressed
□ Dead
of unknown cause
□
□ Loss of weight over time
□ Recumbency
(nonambulatory/down)
□ Reduced milk yield over time
□ Other (note in Block 10)

9. FSIS CONDEMNATION CODES (select one – ONLY if FSIS has made one of these designations)

□ Degen and Dropsic
□ Actinomycosis and Actinobacillosis
Infectious dz.
□ Misc.
□ Arthritis
□ Mastitis
Metritis
□ Pericarditis
□
□ Pneumonia

10. ADDITIONAL DATA/COMMENTS

VS 17-131
FEB 2014

099
101
199
201
203
204
206
208

□ Misc. inflamm dz.
□ Epithelioma
lymphoma
□ Malig
□ Misc. neoplasms
□ Abscess/pyemia
Septicemia
□ Toxemia
□
□ Nonambulatory

299
302
303
399
501
502
503
445

□ Injuries
□ Pigment conditions
□ Myiasis
□ General misc.
□ Residue
Other reportable dz.
□ Misc.
parasitic cond.
□

605
607
402
699
609
900
499

□ Tetanus
□ Vesicular dz.
disorders
□ CNS
□ Dead
□ Moribund
Pyrexia
□ Rabies
□

105
110
601
603
606
608
615