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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. 

UNITED STATES DEPARTMENT OF AGRICULTURE 

ANIMAL AND PLANT HEALTH INSPECTION SERVICE 

NATIONAL VETERINARY SERVICES LABORATORIES 

P.O. BOX 844, 1920 DAYTON AVENUE 

AMES, IOWA 50010 

515-337-7514 

BSE SURVEILLANCE 

SUBMISSION FORM Page of 

OMB Approved 

0579-0409 

1. BSE Referral Number 

2. SUBMITTED BY 3. COLLECTION SITE 

Name (including Business Name) NVSL Submitter ID Premises ID (or Lat/Long) or FSIS Plant Number 

Email Name (including Business Name) 

Phone Fax Street 

Street City State ZIP Code 

City State ZIP Code Phone Fax 

Use separate submission form for each submitter, collector, collection site, and 

collection date combination. Attach a separate Bar Code Sticker (if available) 

for each sample in the spaces below. Attach a separate BSE Surveillance 

Data Collection Form (VS 17-131) for each animal. Sample IDs on this form 

mustatch Sample IDs on BSE Surveillance Data Collection Forms. 

Email 

4. COLLECTION DATE 

5. COLLECTION SITE TYPE (select only one) 

Slaughter Plant Public Health Lab Diagnostic Lab 

Renderer On Farm 3D-4D 

Other (describe) 

6. COLLECTED BY or √ if Same as Submitted by 

Name (including Business Name) 

7. SAMPLE INFORMATION 

Number of Samples ______ 

Preservation Ice Pack Other _________________________________ 

Street 

City State ZIP Code 

Phone Fax 

Email 

1 

BSE Sample ID 

5 

BSE Sample ID 

9 

BSE Sample ID 

13 

BSE Sample ID 

2 

BSE Sample ID 

6 

BSE Sample ID 

10 

BSE Sample ID 

14 

BSE Sample ID 

3 

BSE Sample ID 

7 

BSE Sample ID 

11 

BSE Sample ID 

15 

BSE Sample ID 

4 

BSE Sample ID 

8 

BSE Sample ID 

12 

BSE Sample ID 

16 

BSE Sample ID 

8. Additional Data (attach additional page(s) if needed) 

9. Shipping Date 10. Signature of Submitter 

11. Destination Lab 12. Shipment Tracking Number Accession Number 

Condition Received Distribution Received by Date Received 

VS FORM 17-146 

FEB 2014 
VS FORM 17-146 IINSTRUCTIONS 

Complete a separate submission form for each submitter, 

collector, collection site, and collection date combination. If 

including more than one page, include the page number of total 

pages submitted (e.g., 1 of 3). 

Also complete VS FORM 17-131 (BSE Surveillance Data Collection 

Form) for each animal listed on VS 17-146. 

1. BSE REFERRAL NUMBER 

The number must be a unique identifier for the submission that will not 

be duplicated in any other BSE surveillance submission. The BSE 

Referral Number is used to associate the BSE Surveillance 

Submission Form to the BSE Surveillance Data Collection Form in the 

database. 

The suggested format for the BSE Referral Number consists of 13 or 

14 alphanumeric characters. 

• First two characters are the 2-letter postal abbreviation for 

the State; 

• Next two to three characters are the collector’s initials (First, 

Middle, Last) ; 

• Next eight characters are the collection date in the 

MMDDYYYY format; and 

• Last character is a letter representing which submission form 

of the day it is for the collector (i.e., A=First) 

Example 1. COSAJ06012006A 

Translates to: Colorado – Steven Allen Jones – June 1, 2006 – 

first submission of the day. 

Example 2. COSAJ06012006B 

Translates to: Colorado – Steven Allen Jones – June 1, 2006 -

second submission by Steven Allen Jones for that day, either 

from the same collection site or a different collection site. 

2. SUBMITTED BY 

Enter requested information for the person submitting the sample to 

the laboratory (the submitter). If the samples are being submitted to 

the NVSL, and the submitter has a NVSL Submitter ID, provide it. 

3. COLLECTION SITE 

Enter all the requested data for the collection site. Ensure that the 

National Premises Identification Number (if available) or the FSIS 

Establishment Number where the sample was collected is entered. 

4. COLLECTION DATE 

Enter the date the samples were collected. All samples on one form 

must be collected on the same day. Use the MM/DD/YYYY format. 

5. COLLECTION SITE TYPE 

Select the type of facility where the sample was collected. 

6. COLLECTED BY 

Enter all of the information requested for the person that actually 

collected the tissue sample for submission to the testing laboratory. If 

the Collector is the same as the Submitter, it is only necessary to 

check the indicated box. 

7. SAMPLE INFORMATION 

Specify the number of samples being submitted and the preservation 

method used for transport. For each sample, provide a unique sample 

ID barcode in the BSE Sample ID boxes immediately below Block 7. 

Barcodes are available in the sample kits or barcodes can be ordered 

from the NVSL at ncah.shipping@aphis.usda.gov. In the event that 

barcodes are not available at the time of sample collection, contact the 

VS Area Office so that barcodes can be assigned for the submission. 

8. ADDITIONAL DATA 

Use this block to provide other pertinent information not captured 

elsewhere on the form or VS 17-131. 

9. SHIPPING DATE 

Enter the date the samples are shipped to the laboratory. Use the 

MM/DD/YYYY format. 

10. SIGNATURE OF SUBMITTER 

The submitter must sign the form. 

11. DESTINATION LAB 

Enter the name (or Laboratory ID) of the laboratory where the samples 

are being sent for diagnostic testing. 

12. SHIPMENT TRACKING NUMBER 

Enter the airbill or shipment tracking number for the package(s) being 

sent to the diagnostic laboratory. 

Conditions/Distribution/Received By/Date Received/ Accession 

Number blocks are reserved for use by the testing laboratory.