B08 - Equine Infectious Anemia Test Form Attachment 3.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

1/1/2020

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)

Bruneau ORC

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

BLM, Idaho State Office, 1387 S. Vinnell Way, Boise, ID 83709 5b. PHYSICAL ADDRESS

28536 Jacks Creek Road 7b. MAILING ADDRESS

1387 S. Vinnell Way

5c. CITY, STATE, ZIP CODE

Bruneau, ID 83604

5d. PHONE

208-845-2001

6. COUNTY OF HOME

PREMISES Owyhee 7c. CITY, STATE, ZIP CODE

Boise, ID 83709

7d. PHONE

208-373-3804

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

John Doe, DVM 8b. NATIONAL ACCREDITATION NUMBER

1234567890 8c. VETERINARIAN SIGNATURE 8d. SIGNATURE DATE

8e. VETERINARIAN STREET ADDRESS

123 ABC Lane 8f. CITY, STATE, ZIP

Bruneau, ID 83604

8g. VETERINARIAN PHONE

123-456-7890

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 Idaho 9.

Tube

10. FREEZE MARK NUMBER 15. Sex

F

20. RF

D

22. RH

F

19. LF

A

21. LH

B

17. Head

D

12.Color

F

16. MICROCHIP NUMBER MUST BE RECORDED IF PRESENT

1357924699

14. YOB

Series

11. Tag

1. Individual Accession Number if used 18. Body

None

HMA

ID000

Height

09 32 2345 F A B E A B B

13579246801. Individual Accession Number if used None

ID000

02 32 2112 F A B A A A E

13579246111. Individual Accession Number if used None

ID000

06 32 2222 G E F G F J N

13579245771. Individual Accession Number if used Black and white

ID000

9.

Tube

YOB SEX COLOR

16. MICROCHIP NUMBER MUST BE RECORDED IF PRESENT

1. Individual Accession Number if used

BODY HMA

9.

Tube

YOB SEX COLOR

16. MICROCHIP NUMBER MUST BE RECORDED IF PRESENT

1. Individual Accession Number if used

BODY HMA

9.

Tube

YOB SEX COLOR

16. MICROCHIP NUMBER MUST BE RECORDED IF PRESENT

1. Individual Accession Number if used

BODY HMA

9.

Tube

YOB SEX COLOR

16. MICROCHIP NUMBER MUST BE RECORDED IF PRESENT

1. Individual Accession Number if used

BODY HMA

9.

Tube

YOB SEX COLOR

16. MICROCHIP NUMBER MUST BE RECORDED IF PRESENT

1. Individual Accession Number if used

BODY HMA

9.

Tube

YOB SEX COLOR

16. MICROCHIP NUMBER MUST BE RECORDED IF PRESENT

1. 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

XXXXXXVOIDXXXXXX XXXXXVOIDXXXXX

SAMPLE

ATTACHMENT 3

United States Department of Interior, Bureau of Land Management Group Equine Infectious Anemia Test Form Instructions Sheet

(this form is only for BLM agency use with BLM animals)

The BLM group Equine Infectious Anemia (EIA) Test Form has been approved by the USDA as an official EIA Test Form to accommodate the testing needs of BLM facilities. In accordance with USDA Veterinary Services’ Guidance 15201.1, Approval of Laboratories to Conduct EIA Testing, this form can be accepted by laboratories conducting EIA testing if it is filled out completely with no blanks or missing information. While it is hoped that all states will accept this form as proof of a negative EIA test for interstate movement or sale this cannot be guaranteed as there is no Federal regulation or program that requires individual states to do so.

Form Serial Number: Each page produced by BLM must have a unique Serial Number. The numbering convention used will be <facility or HMA code><mmddyy><-#>.

Where the <facility or HMA code> is the WHBPS code for that location, <mmddyy> is the date the form was produced and <-#> is “-1” for the first form produced that day, “-2” for the second form produced that day etc.

Block 1: Accession Number. Leave blank. This field is for laboratory use only. Labs may assign an accession number to each group of samples at the top of the page or to individual samples on the second line of each animal block at their discretion.

Block 2: Date Blood Drawn. Indicate the date the veterinarian obtained the sample from the animal. This is the official test date.

Block 3: Test Requested by Veterinarian. The veterinarian determines which test should be run by the laboratory -based on the reason for the testing.

Block 4: Reason for Testing. If more than one option applies, mark the most compelling reason for performing the test at this time. Typically Interstate Movement = movement between States or Within State Use/Annual = movement within a State (intrastate), shows/events, or any annual or routine testing will be most often used by BLM.

Block 5: Location of Current Home Premises of the animal at the time the blood is drawn. This should be the physical address of the BLM facility or residence of the animal -where the animal lives at the time the blood is drawn. DO NOT use a Post Office Box. For HMAs this may include the HMA name as well as the name of any specific area within the HMA, name of the nearest town and state. For phone number write NONE.

Block 6: County is the county of the location identified in #5 above. Do not use none.

Block 7: Name and Address of Owner. This must be the name and mailing address of either a BLM facility, BLM contract facility or the name of a BLM Office.

Block 8a: Veterinarian Name. Name of the Accredited Veterinarian who drew the blood sample. DO NOT enter a practice name.

Block 8b: Veterinarian National Accreditation Number.

National Veterinary Accreditation Number of Cat II accredited veterinarian who drew the blood sample.

Block 8c: Signature. Signature of the accredited veterinarian who drew the blood sample. Presigning a blank

EIA Test Form is illegal and can be grounds for suspension of a veterinarian’s National accreditation.

Block 8d: Signature Date The date the veterinarian signed the form.

Blocks 8e, f, g.: Veterinarian Street Address, Phone Number. Physical address and phone number of veterinarian. DO NOT use a Post Office Box.

Remarks: The freeze mark number should be noted as appearing on the left side of the neck. If the animals are unmarked write NO FREEZE MARK. Marked and unmarked animals cannot be recorded on the same form.

State: Record the state where the blood sample was drawn.

Block 9: Tube Number. Record as applicable, per the accredited veterinarian. Some tube identification must be recorded here that matches tube labelling.

Block 10: Freeze Mark Number: If marked the entire freeze mark number must be recorded by filling in Block 14, Series and Block 11, in that order. If the animal is unmarked you must record the age, a tag number or name and write NONE in the Series block.

Block 11: This is the last four digits of the freeze mark number or a neck tag number used on an unmarked animal. The 4 digit neck tag number.

Block 12: Color. Enter coat or hair color(s).

Block 13: Breed of Horse. Circle MUSTANG for horses or circle BURRO or OTHER for mules. A separate form must be used for each species.

Block 14: Year of Birth. This is the first two digits of the freeze mark number.

Series: This is the third and fourth digit of the freeze mark number.

Block 15: Sex. This is the second character of the signalment key. Record that here using the abbreviations G (gelding), M (intact male) and F (female).

Block 16: Microchip Number. The microchip number must be entered if the animal is chipped. A bar code sticker that shows the number may be used. If the animal has not yet been chipped enter NONE.

Blocks 17 - 22: Head markings, limb markings and color may be entered using the BLM signalment key. Additional coat color descriptors (e.g. blank-white, red/white, tri-color, leopard) or obvious scars should be recorded in Block 18 if applicable.

Blank blocks are not acceptable - if none enter NONE.

Blocks 23 - 30: For Laboratory Use Only: Leave blank.

United States Department of Interior, Bureau of Land Management Group Equine Infectious Anemia Test Form Instructions Sheet

(this form is only for BLM agency use with BLM animals)

Blocks 19-22, 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

Block 17, Head 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 Head 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

Block 12, 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