Attachment_4_-_EIA_Test_Form.pdf

UNITED STATES DEPARTMENT OF INTERIOR, BUREAU OF LAND MANAGEMENT

EQUINE INFECTIOUS ANEMIA TEST FORM

BLM AGENCY USE FOR BLM ANIMALS ONLY

FORM SERIAL NUMBER

1. GROUP ACCESSION NUMBER if used 2.DATE BLOOD DRAWN 3. TEST REQUESTED BY VETERINARIAN

ELISA AGID

4. REASON FOR TESTING: Interstate Intrastate/Annual Adoption/Sale Export Illness/Clinical Suspect Investigation/Exposure

5a. NAME of CURRENT HOME PREMISES OF EQUINE (BLM FACILITY or HMA)

7a. NAME AND ADDRESS OF OWNER (MUST BE A BLM FACILITY or OFFICE)

5b. PHYSICAL ADDRESS 7b. MAILING ADDRESS

5c. CITY, STATE, ZIP CODE 5d. PHONE 6. COUNTY OF HOME

PREMISES

7c. CITY, STATE, ZIP CODE 7d. PHONE

I CERTIFY I AM A CATEGORY II FEDERALLY ACCREDITED VETERINARIAN, AUTHORIZED IN THE STATE WHERE THE SAMPLE WAS OBTAINED, BY ME, FROM THE ANIMALS DESCRIBED BELOW 8a. VETERINARIAN NAME 8b. NATIONAL ACCREDITATION NUMBER 8c. VETERINARIAN SIGNATURE 8d. SIGNATURE DATE

8e. VETERINARIAN STREET ADDRESS 8f. CITY, STATE, ZIP 8g. VETERINARIAN PHONE

13. BREED/SPECIES

BURRO MUSTANG MULE

REMARKS: freeze mark number is located on left side of neck - MUST be recorded if present All animals on a form MUST be the same breed or species STATE WHERE SAMPLE WAS

OBTAINED

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10. FREEZE MARK NUMBER 15. Sex 20. RF 22. RH 19. LF 21. LH 17. Head 12.Color 16. MICROCHIP NUMBER MUST BE RECORDED IF PRESENT

14. YOB Series 11. Tag

1. Individual Accession Number if used 18. Body HMA Height

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YOB SEX COLOR

16. MICROCHIP NUMBER MUST BE RECORDED IF PRESENT 1. Individual Accession Number if used

BODY HMA

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YOB SEX COLOR

16. MICROCHIP NUMBER MUST BE RECORDED IF PRESENT1. Individual Accession Number if used

BODY HMA

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YOB SEX COLOR

16. MICROCHIP NUMBER MUST BE RECORDED IF PRESENT1. Individual Accession Number if used

BODY HMA

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YOB SEX COLOR

16. MICROCHIP NUMBER MUST BE RECORDED IF PRESENT1. Individual Accession Number if used

BODY HMA

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YOB SEX COLOR

16. MICROCHIP NUMBER MUST BE RECORDED IF PRESENT1. Individual Accession Number if used

BODY HMA

9.

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YOB SEX COLOR

16. MICROCHIP NUMBER MUST BE RECORDED IF PRESENT1. Individual Accession Number if used

BODY HMA

9.

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YOB SEX COLOR

16. MICROCHIP NUMBER MUST BE RECORDED IF PRESENT1. Individual Accession Number if used

BODY HMA

9.

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YOB SEX COLOR

16. MICROCHIP NUMBER MUST BE RECORDED IF PRESENT1. Individual Accession Number if used

BODY HMA

9.

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YOB SEX COLOR

16. MICROCHIP NUMBER MUST BE RECORDED IF PRESENT1. Individual Accession Number if used

BODY HMA

FOR LABORATORY USE ONLY

23. EIA LABORATORY NAME 24. DATE SAMPLE RECEIVED 25. DATE RESULTS REPORTED 26. OFFICIAL TEST RESULT 27. TEST TYPE USED

☐ Negative ☐ Positive ☐ AGID ☐ ELISA

28. LABORATORY REMARKS

23a. CITY 23b. STATE 29. SIGNATURE OF NVSL - APPROVED EIA TECHNICIAN

30. INTERIM RESULT REFERRED FOR CONFIRMATION ☐

Official EIA Test Form, Approved by USDA Veterinary Services APR 2020, U.S. Department of Interior, Bureau of Land Management Leg Markings: A – No White, B – Coronet, C – Half Pastern, D – Full Pastern, E – Sock, F – Stocking, G – Over Knee/Hock, H – Striped Below Knee, I – Striped Above Knee, Y – Not Examined, Z – Other Face Markings (Horses & Light Muzzled Burros): A – No Markings, B – Star, C – Strip, D – Snip, E – Star-Strip, F – Star-Snip, G – Strip-Snip, H – Star-Strip-Snip, I – Blaze, J – Bald, K – Frosted Face Markings (Dark Muzzled Burros): M – No Markings, N – Star, O – Strip, P – Snip, Q – Star-Strip, R – Star-Snip, S – Strip-Snip, T – Star-Strip-Snip, U – Blaze, V – Bald, W – Frosted Color: A – White, B – Bay, C – Black, D – Brown, E – Sorrel, F – Chestnut, G – Gray, H – Grulla, I – Roan-Strawberry, J – Roan-Red, K – Roan-Blue, L – Buckskin, M – Dun, N – Pinto, O – Palomino, P – Appaloosa, Q – Pink Burro, R – Blue Burro, S – Red Burro, Z - Other

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