According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it

displays a valid OMB control number. The valid OMB control number for this information collection is 0579-0409. The time required to complete this information collection 

is estimated to average 6 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, 

and completing and reviewing the collection of information.

OMB APPROVED 

0579-0409

UNITED STATES DEPARTMENT OF AGRICULTURE

ANIMAL AND PLANT HEALTH INSPECTION SERVICE

VETERINARY SERVICES

BSE SURVEILLANCE DATA COLLECTION FORM 

1. PRIMARY REASON FOR SUBMISSION (check the selection with the smallest number that applies) 

1. Highly suspicious for BSE

2. FSIS, antemortem condemned cattle

3. Rabies suspect

4. CNS signs

5. Nonambulatory/Disabled/Downer

6. Other clinical signs that may be associated with

BSE as noted below

7. Dead

2. BSE Referral Number 

(must agree with # on VS 17-146)

3. INDIVIDUAL DETERMINING PRIMARY REASON (BLOCK 1) AND CLINICAL SIGNS (BLOCK 13) (select one) 

1. Veterinarian employed by APHIS

2. Veterinarian employed by FSIS

3. Other Veterinarian

4. Other APHIS personnel

5. Renderer/deadstock hauler/3D-4D

6. Producer/owner

7. Other (describe in Block 10) 

4. BSE Sample ID 

Please use barcode, if available

5. OWNER INFORMATION

Name (including Business Name)

Street

City State ZIP Code

Country (if not USA) Premises ID or Lat/Long

Phone Fax

County Email

6. SLAUGHTER SITE OR √ if same as Collection Site on VS 17-146 

(complete only if slaughtered at State or FSIS-inspected facility) 

Premises ID or FSIS Plant Number 

Name (including Business Name)

Street

City State ZIP Code

Phone Fax

Email

7. ANIMAL INFORMATION 

a. Animal Breed (if known)

If breed not known:

Beef Breed Primary Colors:

Dairy Breed

Months b. Age_______

Years

Dentition: 2nd Set of Incisors Erupted

Age is:

Yes

No

Estimated

Recorded

c. Gender

Female

Male 

Unknown

d. Neutered

Yes

No

Unknown

e. Country of Origin (only if 

KNOWN to be other than USA)

f. Official USDA Tag No. g. FSIS Condemnation Tag No.

Zh. Back Tag No. i. Microchip No.

j. Collection Site Tracking No. k. Slaughter Tracking No. l. Owner Ear Tag No. m. Other ID No.

8. CLINICAL SIGNS (select all that apply) 

Abnormal head carriage

Aggressive or belligerent

Apprehensive or nervous

Ataxia (abnormal gait, 

uncoordinated)

Blindness

Circling

Droopy lip or eyelid

Excessive bellowing

Excessive licking

Excitable

Head pressing/rubbing

Head shyness

Hyperesthesia (sensitivity to light or sounds, 

shifting ears)

Hesitation at doors, gates, or barriers

Kicking while milking (when did not before)

Paralysis

Tremors or nystagmus

(includes eye movements, head tremors) 

Signs marked at left:

Worsened over time

Did not worsen

Don’t know

The animal:

Responded to treatment

Did not respond

Don’t know

Other signs observed:

Depressed

Dead of unknown cause

Loss of weight over time

Recumbency

(nonambulatory/down)

Reduced milk yield over time

Other (note in Block 10)

9. FSIS CONDEMNATION CODES (select one – ONLY if FSIS has made one of these designations) 

Degen and Dropsic 099

Actinomycosis and Actinobacillosis 101

Misc. Infectious dz. 199

Arthritis 201

Mastitis 203

Metritis 204

Pericarditis 206

Pneumonia 208

Misc. inflamm dz. 299

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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***THIS FORM MUST BE USED IN CONJUNCTION WITH VS 17-146 (BSE SURVEILLANCE SUBMISSION FORM). DO NOT SUBMIT ALONE.*** 

→ 

→

Epithelioma 302

Malig lymphoma 303

Misc. neoplasms 399

Abscess/pyemia 501

Septicemia 502

Toxemia 503

Nonambulatory 445

Injuries 605

Pigment conditions 607

Myiasis 402

General misc. 699

Residue 609

Other reportable dz. 900

Misc. parasitic cond. 499

Tetanus 105

Vesicular dz. 110

CNS disorders 601

Dead 603

Moribund 606

Pyrexia 608

Rabies 615

10. ADDITIONAL DATA/COMMENTS 

VS 17-131

FEB 2014