Director of lab:      

Lab Name (for certificate):     

Address:      

City, State, Zip code:     

Contact person:      

Phone:       Fax:      

E-mail:      

Please verify the above information and make any corrections necessary.

Return this test result form by **June 13, 2008** to:

**Results will not be accepted for approval after the June 13, 2008
deadline.**

Randy Capsel E-mail: Randy.T.Capsel@aphis.usda.gov

Mycobacteria and Brucella Section Fax: 515-663-7315

USDA, APHIS, VS, NVSL Phone: 515-663-7151

1800 Dayton Avenue

Ames, IA 50010

Kit number received:       Date kit received:      

Condition of samples when they arrived. Satisfactory Unsatisfactory

If unsatisfactory, please explain.     

**Procedure tested with designated kit:**

Direct PCR

Commercial Kit: In-House Procedure:

Commercial Manufacturer:      

DNA Extraction Kit Serial #:       Expiration Date:      

DNA Probe Kit Serial **\#      ** Expiration Date:      

How many Johne's Disease fecal tests does your lab perform each
year?     

What is your test capacity?     

**Lab Reporting Procedures:**

This laboratory reports culture results as follows (select all that
apply):

Shedding Status Category Colony Counts Pos/Neg Other (explain)      

**Detection method used.**

Has it changed from last year? \_\_\_\_\_ If so, please submit current
protocol.

**Vial #26 is a positive control sample**.

Kit \#      

  --------- --------------- --------- ---------- ------------- ----------------
            **Ct Replicate            **Avg Ct   **Sample      **Shedding
            Well Data (if             Value**    Result**      Status**
            applicable)**                                      

  **Vial    **Well 1**      **Well    **Ct**                   
  ID**                      2**                                

  1                                                            

  2                                                            

  3                                                            

  4                                                            

  5                                                            

  6                                                            

  7                                                            

  8                                                            

  9                                                            

  10                                                           

  11                                                           

  12                                                           

  13                                                           

  14                                                           

  15                                                           

  16                                                           

  17                                                           

  18                                                           

  19                                                           

  20                                                           

  21                                                           

  22                                                           

  23                                                           

  24                                                           

  25                                                           

  26 (+)                                                       
  --------- --------------- --------- ---------- ------------- ----------------

We the undersigned, recognizing that some special handling may be
required due to the nature of proficiency testing material, have as
closely as is practical, performed the analyses on these specimens in
the same manner as regular patient specimens.

Director (or Designee)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_(signature)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_(print)

Email results to: <Randy.T.Capsel@aphis.usda.gov>

Alternatively, fax results: Randy Capsel 515-663-7315

Submission deadline: **June 13, 2008. Results will not be accepted for
approval purposes after the stated deadline.**

Results may also be mailed to: Randy Capsel, USDA, NVSL, 1800 Dayton
Ave. Ames, IA 50010