< > Glossary & References / Book List / B36 Field Manual of Wildlife Diseases / Text Sections:
wait to load, then scroll down)

image2.gif (1889 bytes)Field Manual of Wildlife Diseases
Click here for CONTENTS Page
For contact details see Title Page

Appendix A - Sample Specimen History Form

(To print this form - use the File>Print... command on your browser menu at the very top of your page)

Submitter's name:  


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



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)  





Return to top of page