VS 5-29 Cooperative State - Scrapie Control Program

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 0579-0101. The time required to complete this information collection is estimated to average .3 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.
OMB Approved
STATE

ALL INCOMPLETE RECORDS WILL BE RETURNED FOR COMPLETION

A

COOPERATIVE STATE - FEDERAL SCRAPIE CONTROL PROGRAM

REFERRAL NO. (e.g. COBTP050120231)

SCRAPIE TEST RECORD
FIRST

COUNTY OF OWNER

FLOCK OWNER'S NAME - LAST

FLOCK ID

FLOCK OWNER'S COMPLETE ADDRESS

PREVIOUS TEST DATE

I l
MI

I

L
FLOCK OWNER'S TELEPHONE NUMBER

REASON FOR TEST
1
SURVEILLANCE

SUSPECTED
8

2
POSITIVE

EXPOSED
3

SFCP

4

HIGH RISK
TRACE TO
FLOCK

5

OWNER'S
REQUEST

9
INFECTED
OR SOURCE
RSSS POS.
10
INFECTED
OR SOURCE
NOT RSSS)

I

Specimen #

YES

□

KIND OF FLOCK

□

SHEEP

□

GOAT

I

NO

VETERINARIAN'S SIGNATURE

VETERINARIAN'S NAME (Please print)

NO. OF ANIMALS IN FLOCK

COLLECTION DATE

VETERINARIAN'S ADDRESS

MIXED

□
□

TELEPHONE NO

OTHER

GENOTYPE LAB TURN AROUND TIME

□

5 DAY TURNAROUND

□

10 DAY TURNAROUND

FAX NO. OR E-MAIL ADDRESS

AGREEMENT NO.

TEST TYPE

12
RETEST/
OTHER

□

COMPLETE FLOCK TEST OF ALL ELIGIBLE ANIMALS:

MISSING 11
EXPOSED
EWE (ME)

6
IMPORT/
EXPORT

COUNTY OF FLOCK

7

TOTAL # OF
SAMPLES

VET ACCRED. # / PERSON ID

CERTIFICATION FOR PAYMENT
Owner's
Cooperative
Federal
□ Expense
□ Agreement
□ Expense
I certify:
That this test was made by me on the animals identified below on the dates
as entered in appropriate spaces. That when payment is claimed at program
expense in accordance with agreement number below, no payment has been
or will be received from any other source.

FARM RISK LEVEL2

□H □M

0579-0101 Exp 05/2027

□

SHEEP:

□

RECTAL BIOPSY

GOAT:

□

RECTAL BIOPSY

□

136 CODON

□

146 CODON

□

171 CODON

□

222 CODON

OTHER

FLOCK STATUS

□

SFCP

□

NONE

□

OTHER

Other ID Numbers

Official ID Number(s)

Designation
pos, sus,
exp, me, n/a

□
□
Age

EXPOSED

□

INFECTED

SOURCE

□

INVEST

Breed
Sex
(m,f,cm) (if unkn,
face)

Rectal Biopsy
Sample Loc
(Type one #)3

@
@
@
@
4

4

4

4

NOTE: Sample numbers on specimens must be the same as listed on this form.
DSE/VMO Name:
Address:

Phone Number:
Fax Number:
E-Mail:

VS FORM 5-29
JAN 2025

1 Referral

Number Format: State abbreviation, collector's initials, collection date.

2 For

farms where a scrapie risk factor questionnaire was completed, check appropriate box.

3 For

animals that may be sampled multiple times, e.g. ,SFCP or Exposed animals, type the

quadrant number in the space next to the diagram.
Remarks:

DATE

I

OWNER'S SIGNATURE:

I hereby acknowledge receiving a copy of this record which I have examined and find correct.