Details to be Included When Sending Samples

1. Information of the Person Sending the Sample

• Name:

• Contact Number:
  ☐ Farmer ☐ Technician ☐ Veterinarian

• Organization Name (if any):

• Date:

2. Address Where the Sample Was Collected

• Province:

• District:

• Municipality/Rural Municipality:

• Ward No.:

• Locality/Farm Name (if any):

• GPS:

3. Details of the Animal/Poultry from Which the Sample Was Collected

• Species:
  ☐ Cattle ☐ Buffalo ☐ Goat ☐ Sheep ☐ Pig ☐ Chicken ☐ Dog ☐ Other: ________

• Breed (if known):

• Age: ...........

• If age is unknown, age group:
  ☐ Under 6 months ☐ 6–12 months ☐ Above one year

• Number of animals at risk:

• Number of affected animals:

• Number of dead animals (if any):

4. Symptoms Related to the Disease
☐ Fever
☐ Diarrhea
☐ Cough
☐ Nasal crusting
☐ Nasal discharge
☐ Lameness
☐ Skin rash/wound/lump
☐ Abortion
☐ Sudden death
☐ Nervous signs (e.g., staggering)
☐ Sudden illness in large numbers
☐ Decreased production (milk/eggs)
☐ Other symptoms: ___________________________

5. Disease Timeline

• Date when symptoms were first observed:

• Is the disease spreading? ☐ Yes ☐ No

• Have new animals been introduced recently? ☐ Yes ☐ No

• Were animals taken to pasture? ☐ Yes ☐ No

• Were animals vaccinated in the last 6 months? ☐ Yes ☐ No

• Vaccinated against which disease(s)?:

• Any recent changes in diet or management? ☐ Yes ☐ No (If yes, specify: ____________)

• Have sick animals come into contact with wild animals? ☐ Yes ☐ No

6. Samples Collected
☐ Blood
☐ Feces
☐ Eye/Nose/Mouth Swab
☐ Organ: ...........................
☐ Skin sample
☐ Serum
☐ Milk
☐ Urine
☐ Milk
☐ Water
☐ Environmental swab
☐ Other: __________

• Sample collection date:

• Sample storage/transport method:

• Date sample sent: ________

• Laboratory sent to: ________

7. Suspected Disease Name (if any): _____________

9. Suggestions / Comments

Signature
Date: ___________