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
- Grand Traverse County, Lansing City, Michigan
About this file
This document is a Chronic Wasting Disease (CWD) tag sample form issued by the Michigan Department of Agriculture and Rural Development (MDARD) Animal Industry Division for cervidae specimens only. The form serves as an official tracking and certification document for deceased cervid animals submitted for CWD testing. The AI-027 form (Revision 07/2017) contains five identical tag sets (numbered 128001 through 128005), each designed to collect specimen information including herd registration number, official ID, breed, age, sex, date of death, cause of death, pickup and delivery dates, and collector/veterinarian information. Submitters are required to use a Sharpie Extra-Fine Point Permanent Marker and specify the specimen type (head, fresh, frozen, fixed tissue, or full carcass) in accordance with Act 466 of 1988 as amended. Each tag includes designated sections for producer and MDARD representative signatures with dates, with one portion retained by the submitter for their records.
The document contains no pricing terms, set-asides, incumbent information, or funding details, as it functions as an administrative specimen submission form rather than a procurement document. Submitters must complete all required fields to certify that the identified animal died from the stated cause of death and originated from the specified herd. The MDARD Animal Industry Division can be contacted at 800-292-3939 for submission guidance or inquiries. This form represents the standardized procedure for documenting and tracking cervid specimens for disease surveillance and testing purposes within Michigan's agricultural regulatory framework.
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Other files
| File | Type | Posted |
|---|---|---|
| State of Michigan Print Mail Management Terms Conditions (1).docx | DOCX document | |
| AI-027 CWD Tag 8-25.docx | DOCX document | |
| Standard Contract Terms - Short Form.pdf |
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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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