AI-027 CWD Tag Sample 9-21.pdf
PDF 71 KB Posted
- Attached to
- AI-207 CWD TAG
- Solicitation number
- RFQ-171-250000000612-1
- Issued by
- Michigan
About this file
This document is a series of Cervidae Specimen Submission Forms issued by the Michigan Department of Agriculture and Rural Development (MDARD), specifically the Animal Industry Division. The forms are designed for tracking and documenting deceased cervid (deer/elk) animals, with unique specimen numbers ranging from 128001 to 128005. Each form provides fields for detailed information including specimen identification, herd registration, official and other identification numbers, breed, age, sex, date of death, cause of death, date of pickup and delivery, collector/veterinarian details, and producer/facility information.
The forms are standardized data collection instruments used in accordance with Act 466 of 1988 (as amended), allowing for systematic documentation of cervid animal deaths. The forms include options for specimen type (head, fixed tissue, full carcass) and specimen condition (frozen, fresh), with specific tracking codes like CW 40058 and TB C28405. The forms are to be completed using a Sharpie Extra-Fine Point Permanent Marker and are meant to be retained by the submitter for their records. Contact for inquiries is provided as the MDARD Animal Industry Division, reachable at 800-292-3939.
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Other files
| File | Type | Posted |
|---|---|---|
| Standard Contract Terms - Short Form.pdf | ||
| AI-027 CWD Tag 8-25.docx | DOCX document | |
| State of Michigan Print Mail Management Terms Conditions (1).docx | DOCX document |
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Text version
SPECIMEN # HERD REGISTRATION
OFFICIAL ID OTHER ID
BREED AGE SEX
DATE OF DEATH CAUSE OF DEATH
DATE OF PICKUP DATE OF DELIVERY
COLLECTOR/VETERINARIAN
PRODUCER/FACILITY NAME
ADDRESS
CITY STATE ZIP CODE
TELEPHONE
AI-027 (Rev. 07/2017) Michigan Department of Agriculture and
Rural Development
CERVIDAE
ONLY
SPECIMEN #
Use Sharpie Extra-Fine Point Permanent Marker
□ HEAD □ CW 40058 □ FROZEN
□ FIXED TISSUE □ TB C28405 □ FRESH
□ FULL CARCASS
(IN ACCORDANCE WITH ACT 466 OF 1988 AS AMENDED)
This potion to be retained by the submitter for their records.
Michigan Department of Agriculture and Rural Development Animal Industry Division Telephone: 800-292-3939
128001
128001
!128001!
I c er tif y th at th e an im al id en tifi ed o n th e re ve rs e si de o f t hi s ta g di ed fr om th e ca us e of d ea th a nd is fr om th e he rd id en tifi ed b y th e re gi st ra tio n nu m be r l is te d.
Pr od uc er
N am e (p rin te d)
Pr od uc er
S ig na tu re
Da te
M
DA
RD
R ep re se nt at iv e Na m e
(p rin te d)
M
DA
RD
R ep re se nt at iv e/ Ve te rin ar ia n Si gn at ur e
BREED AGE SEX
DATE OF DEATH CAUSE OF DEATH
DATE OF PICKUP DATE OF DELIVERY
COLLECTOR/VETERINARIAN
PRODUCER/FACILITY NAME
ADDRESS
CITY STATE ZIP CODE
TELEPHONE
AI-027 (Rev. 07/2017) Michigan Department of Agriculture and
Rural Development
CERVIDAE
ONLY
SPECIMEN #
Use Sharpie Extra-Fine Point Permanent Marker
□ HEAD □ CW 40058 □ FROZEN
□ FIXED TISSUE □ TB C28405 □ FRESH
□ FULL CARCASS
(IN ACCORDANCE WITH ACT 466 OF 1988 AS AMENDED)
This potion to be retained by the submitter for their records.
Michigan Department of Agriculture and Rural Development Animal Industry Division Telephone: 800-292-3939
128002
128002
!128002!
tif y th at th e an im al id en tifi ed o n th e re ve rs e si de o f t hi s ta g di ed fr om e of d ea th a nd is fr om th e he rd id en tifi ed b y th e re gi st ra tio n nu m be r l is te d.
Pr od uc er
N am e (p rin te d)
Pr od uc er
S ig na
M
DA
RD
R ep re se nt at iv e Na m e
(p rin te d)
M
DA
RD
R ep re se nt at iv e/ Ve te rin ar ia n Si gn at ur e
BREED AGE SEX
DATE OF DEATH CAUSE OF DEATH
DATE OF PICKUP DATE OF DELIVERY
COLLECTOR/VETERINARIAN
PRODUCER/FACILITY NAME
ADDRESS
CITY STATE ZIP CODE
TELEPHONE
AI-027 (Rev. 07/2017) Michigan Department of Agriculture and
Rural Development
CERVIDAE
ONLY
SPECIMEN #
Use Sharpie Extra-Fine Point Permanent Marker
□ HEAD □ CW 40058 □ FROZEN
□ FIXED TISSUE □ TB C28405 □ FRESH
□ FULL CARCASS
(IN ACCORDANCE WITH ACT 466 OF 1988 AS AMENDED)
This potion to be retained by the submitter for their records.
Michigan Department of Agriculture and Rural Development Animal Industry Division Telephone: 800-292-3939
128003
128003
!128003!
tif y th at th e an im al id en tifi ed o n th e re ve rs e si de o f t hi s ta g di ed fr om e of d ea th a nd is fr om th e he rd id en tifi ed b y th e re gi st ra tio n nu m be r l is te d.
Pr od uc er
N am e (p rin te d)
Pr od uc er
S ig na
M
DA
RD
R ep re se nt at iv e Na m e
(p rin te d)
M
DA
RD
R ep re se nt at iv e/ Ve te rin ar ia n Si gn at ur e
BREED AGE SEX
DATE OF DEATH CAUSE OF DEATH
DATE OF PICKUP DATE OF DELIVERY
COLLECTOR/VETERINARIAN
PRODUCER/FACILITY NAME
ADDRESS
CITY STATE ZIP CODE
TELEPHONE
AI-027 (Rev. 07/2017) Michigan Department of Agriculture and
Rural Development
CERVIDAE
ONLY
SPECIMEN #
Use Sharpie Extra-Fine Point Permanent Marker
□ HEAD □ CW 40058 □ FROZEN
□ FIXED TISSUE □ TB C28405 □ FRESH
□ FULL CARCASS
(IN ACCORDANCE WITH ACT 466 OF 1988 AS AMENDED)
This potion to be retained by the submitter for their records.
Michigan Department of Agriculture and Rural Development Animal Industry Division Telephone: 800-292-3939
128004
128004
!128004!
tif y th at th e an im al id en tifi ed o n th e re ve rs e si de o f t hi s ta g di ed fr om e of d ea th a nd is fr om th e he rd id en tifi ed b y th e re gi st ra tio n nu m be r l is te d.
Pr od uc er
N am e (p rin te d)
Pr od uc er
S ig na
M
DA
RD
R ep re se nt at iv e Na m e
(p rin te d)
M
DA
RD
R ep re se nt at iv e/ Ve te rin ar ia n Si gn at ur e
BREED AGE SEX
DATE OF DEATH CAUSE OF DEATH
DATE OF PICKUP DATE OF DELIVERY
COLLECTOR/VETERINARIAN
PRODUCER/FACILITY NAME
ADDRESS
CITY STATE ZIP CODE
TELEPHONE
AI-027 (Rev. 07/2017) Michigan Department of Agriculture and
Rural Development
CERVIDAE
ONLY
SPECIMEN #
Use Sharpie Extra-Fine Point Permanent Marker
□ HEAD □ CW 40058 □ FROZEN
□ FIXED TISSUE □ TB C28405 □ FRESH
□ FULL CARCASS
(IN ACCORDANCE WITH ACT 466 OF 1988 AS AMENDED)
This potion to be retained by the submitter for their records.
Michigan Department of Agriculture and Rural Development Animal Industry Division Telephone: 800-292-3939
128005
128005
!128005!
tif y th at th e an im al id en tifi ed o n th e re ve rs e si de o f t hi s ta g di ed fr om e of d ea th a nd is fr om th e he rd id en tifi ed b y th e re gi st ra tio n nu m be r l is te d.
Pr od uc er
N am e (p rin te d)
Pr od uc er
S ig na
M
DA
RD
R ep re se nt at iv e Na m e
(p rin te d)
M
DA
RD
R ep re se nt at iv e/ Ve te rin ar ia n Si gn at ur e
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