AI-027 CWD Tag Sample 9-21.pdf
PDF 71 KB Posted
- Attached to
- AI-027 CWD TAG
- Solicitation number
- RFQ 171 230000000749 1
- Issued by
- Grand Traverse County, Lansing City, Michigan
About this file
This is a specimen collection tag form issued by the Michigan Department of Agriculture and Rural Development (MDARD) Animal Industry Division for the submission of cervidae (deer family) samples related to Chronic Wasting Disease (CWD) surveillance and testing. The AI-027 form, revised July 2017, serves as an official documentation and chain-of-custody record for animal specimens submitted for laboratory analysis. The form requires submission of specimen information including herd registration numbers, official and other identification, breed, age, sex, date of death, cause of death, pickup and delivery dates, and collector/veterinarian information. Specimen types accepted include head samples, frozen materials, fixed tissue, fresh samples, and full carcasses, with specific reference to Act 466 of 1988 as amended. The document contains five identical tag sets numbered 128001 through 128005, with each tag requiring signatures from both the producer and MDARD representative or veterinarian to certify the animal's identity and cause of death.
The form functions as a dual-copy system, with one portion retained by the submitter for their records and the official copy submitted to the MDARD Animal Industry Division. Specimens may be submitted in various conditions (frozen, fresh, or fixed tissue) and include either head samples or full carcasses. The form includes designated fields for specimen number, herd registration, official identification numbers, and complete facility and contact information. Instructions specify the use of Sharpie Extra-Fine Point Permanent Marker for marking specimens. The contact number for the MDARD Animal Industry Division is 800-292-3939. This form is part of Michigan's disease surveillance program for cervidae operations and does not contain pricing information, set-asides, or funding requirements typical of procurement solicitations.
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Other files
| File | Type | Posted |
|---|---|---|
| State of Michigan Print Mail Management Terms Conditions.docx | DOCX document | |
| AI-027 CWD Tag 8-23.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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