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Appendix A - Sample Specimen History Form

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Submitter's name:  
Affiliation:  
Address:  

 

Telephone:  
E-mail:  
Date collected:  
Method of collection: (found dead, euthanized (describe method) etc.)  
Collector's name:  
Specific die-off location:  

 

 

State:  
County:  
Latitude / longitude  
Environmental factors: (Record conditions such as storms, precipitation, temperature changes, or other changes that may contribute to animal stress.)  

 

 

 

Disease onset: (Your best estimate of when the outbreak started.)  

 

 

 

Species affected: (The diversity of species affected may provide clues to the disease involved.)  

 

 

Age/sex: (Any selective mortality related to age and sex.)  

 

Morbidity/mortality: (Ratio of sick animals to dead animals.)  

 

Known dead: (Actual pickup figures.)  

 

Estimated dead: (Consider removal by scavengers or other means.)  

 

Clinical signs: (Any unusual behavior and physical appearance.)  

 

 

 

Population at risk: (Number of animals in the area that could be exposed to the disease.)  

 

 

 

Population movement: (Recent changes in the number of animals on the area and their source or destination, if known.)  

 

 

Problem area description: (Land use, habitat types, and other distinctive features.)  

 

 

 

Comments: (Additional information/observations that may be of value such as past occurrences of disease in area)  

 

 

 

 

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