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 numbers for this information collection are 0579-0040, 0579-0090, 0579-0101, 0579-0146, 0579-0189 and 0579-0485. The time required to 

complete this information collection is estimated to average 15 minutes to 1 hour 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 

0579-0040, 579-0090, 

0579-0101, 0579-0146, 

0579-0189, 0579-0485

UNITED STATES DEPARTMENT OF AGRICULTURE 

ANIMAL AND PLANT HEALTH INSPECTION SERVICE 

NATIONAL VETERINARY SERVICES LABORATORIES 

P.O. BOX 844, 1920 DAYTON AVENUE, AMES, IA 50010 

515-337-7266 

SPECIMEN SUBMISSION 

PAGE 

OF 

INSTRUCTIONS: Use a separate form for each species and each owner/broker. See “Instructions for Completing VS Form 10-4” for definitions. 

1. SUBMITTER NAME (Including Business Name) 2. NVSL SUBMITTER ID 3. NAME OF OWNER Check if wildlife (No owner) 

EMAIL ADDRESS OWNER CITY STATE/COUNTRY 

PHONE NUMBER FAX NUMBER 

MAILING ADDRESS (Street, City, State, ZIP Code) 

4. LOCATION OF ANIMALS

5. PAYMENT METHOD

PREMISES ID 

COUNTY STATE/COUNTRY 

USER FEE ACCOUNT NO. CHECK/MONEY ORDER 

(Enclosed, payable to USDA in U.S. dollars) 

Credit Card Number: 

Expiration Date: 

6. HERD/FLOCK SIZE 

7. NUMBER IN HERD/FLOCK AFFECTED 

8. NUMBER IN HERD/FLOCK DEAD 

9. EXAMINATIONS REQUESTED 10. COLLECTED BY 

11. DATE COLLECTED 

12. AUTHORIZED BY 

13. PURPOSE OF SUBMISSION (See instructions for definitions) 

Interstate Movement Import TB Reagent Evaluation 

Export FAD/EP Diagnostic General Diagnostic NVSL Intralab 

Pre-Import Surveillance Developmental Research 

14. COUNTRY OF ORIGIN / DESTINATION

15. REFERRAL NUMBER 

16. PRESERVATION

None Ice Pack Formalin Borax Alcohol Other (Specify) 

17. SPECIMENS SUBMITTED (“X” applicable item(s))

Blood Feces Parasite Serum Tissue (Specify) Whole Animal 

Culture Feed Plant Soil Urine Fetus 

Extract Milk Semen Swab (Specify) Water DNA/RNA 

Other (Specify) 

18. TOTAL NUMBER OF 

SPECIMENS SUBMITTED 

19. SPECIES OR SOURCE (“X” ONLY one) 

Cattle Goat Chicken Bison Fish 

Swine Horse Turkey Deer (Specify) Environment 

Sheep Donkey Other bird (Specify) Elk Reagent 

Sample ID Animal ID Breed Age Sex Sample ID 

Other (Specify) 

Animal ID 

20. NUMBER OF ANIMALS 

SAMPLED

Breed Age Sex 

221. IDENTIFICATION (See Instructions <250 samples per form) 1. IDENTIFICATION (See instructions <250 samples per form)

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4. LOCATION OF ANIMAL

5. PAYMENT METHOD 

IDENTIFICATION 

22. ADDITIONAL DATA (History, clinical signs, post mortem findings, remarks, tentative diagnosis, special instructions. Use additional sheets, if necessary). 

23. SIGNATURE OF SUBMITTER AND DATE NVSL USE ONLY 

NVSL USE ONLY 

CONDITION PRIORITY DISTRIBUTION RECEIVED BY 

VS FORM 10-4 

JUN 2022 
VS FORM 10-4 INSTRUCTIONS 

ALL information must be printed legibly or typed. Use a separate form for each 

species and owner. At the minimum, complete all fields designated in these 

instructions as required. Contact the Receiving Department of the laboratory to 

which you are sending specimens with specific documentation or shipping 

questions. 

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

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

1. SUBMITTER CONTACT INFORMATION “REQUIRED” 

Enter the submitter’s business name/affiliation; the name of the individual 

submitter is optional if test results are returned to a general business fax, email, 

or mailing address. Enter a fax number or email address to which APHIS can 

return test results. Multiple email addresses are permissible. Specify if there is a 

preferred method of report delivery; email will be used if no preference is stated. 

Provide a complete mailing address. If fax or email is not available, test reports

can be mailed, but this will delay delivery of results. Repeat submitters are 

encouraged to be consistent with the submitter contact information that is 

provided, as the NVSL keeps a master record. If the test report for an individual 

submission needs to be routed to a non-standard destination, include special 

instructions in Block 22, Additional Data. 

2. NVSL SUBMITTER ID 

For more efficient service, repeat submitters are encouraged to include their 

NVSL Submitter ID. If you do not know your ID, contact the NVSL at 

515-337-7266. 

3. OWNER INFORMATION “REQUIRED” 

Enter the complete name of the animal owner, the city and the two-letter 

abbreviation of the State in which the owner resides. Ensure the animal owner is 

identified here and not the property manager or veterinarian. For wildlife, check 

the box to indicate there is no owner. 

4. LOCATION OF THE ANIMALS “REQUIRED” 

Include National Animal Identification System (NAIS) premises ID, if available. 

Also, specify the county, parish, or other designated location of the animals and 

the two-letter State abbreviation. 

5. PAYMENT METHOD “REQUIRED FOR BILLABLE CASES” 

Check the appropriate payment method. If payment is by user account or credit 

card, enter the account number. Enter the expiration month and year when using 

a credit card. Refer to the User Fees/Payment Options and the Catalog of 

Services/Fees, both located at

www.aphis.usda.gov/animal_health/lab_info_services/diagnos_tests.shtml, for 

specific test fees and a list of accepted credit cards. DO NOT SEND CASH. 

6. HERD/FLOCK SIZE

Enter the total number of animals in the herd/flock. 

7. NO. IN HERD/FLOCK AFFECTED 

Enter the total number of animals in direct contact with suspect animal or 

showing clinical signs. 

8. NO. IN HERD/FLOCK DEAD 

Enter the total number of animals from this herd/flock that are dead. 

9. EXAMINATIONS REQUESTED “REQUIRED” 

For disease programs, it is necessary only to enter the program name 

(e.g., CWD, Scrapie, or BSE). If the test is not for a disease program, specify the 

disease and the desired test. 

10. COLLECTED BY 

Enter the complete name of the person collecting the specimen(s). 

11. DATE COLLECTED 

Enter the date on which specimens were collected. Use the format 

DD/MM/YYYY.

12. AUTHORIZED BY 

Enter the name of the person authorizing the submission of this sample. 

Normally, this is the Area Veterinarian in Charge (AVIC) in your State. 

Authorization is assumed for regulatory veterinarians making routine program 

specimen submissions. See 

http://www.aphis.usda.gov/animal_health/area_offices/ to locate the AVIC in your 

local area. 

If an exotic (foreign) disease is suspected, contact the AVIC and the Emergency 

Programs staff to obtain authorization to submit samples for FAD testing and an 

investigation control number that must be included with the submission. DO 

NOT ship any such specimens until approval is received and a control number is 

assigned. The receipt of an unauthorized shipment of specimens containing 

exotic disease agents can cause substantial disruption of work at the laboratory 

and result in possible fines for the submitter. 

13. PURPOSE OF SUBMISSION “REQUIRED” 

Definitions of Diagnostic Case Categories are as follows: 

Interstate Movement – Tests conducted for the purpose of qualifying live animals 

or poultry for interstate movement. 

Export – Tests conducted for the purpose of qualifying animals or poultry, 

including wild animals and birds, or animal or poultry products for export from the 

U.S. to a foreign country. 

Pre-Import – Tests conducted for the purpose of qualifying animals or poultry,

including wild animals and birds, or animal or poultry products for import into the 

U.S. Select this purpose when the animals or products have not yet been moved

into the U.S. 

Import – Tests conducted for the same purpose as pre-import except that the 

animals or products are currently located at a U.S. import center. 

FAD/EP Diagnostic – Tests conducted for the purpose of diagnosing or 

confirming a foreign disease, or for the eradication of a foreign disease that has 

gained entrance into the U.S. If a foreign animal disease is suspected, follow 

instructions in Block 12 for authorization to submit a FAD specimen. 

Surveillance – Tests conducted for monitoring for a specific disease, for a 

specific insect or insect vector, or for analyzing specific products that are used in 

treating animals or poultry or for decontamination of animal poultry facilities.

TB – Tests conducted for diagnosing Tuberculosis. 

General Diagnostic Case – Tests conducted for the purpose of diagnosing or 

confirming a domestic disease, and/or the analysis of environmental products 

that may be contributing to an existing disease condition. Use this purpose when 

the purposes listed above do not apply. 

Developmental/Research – Tests conducted for the purpose of supporting a 

developmental or research project conducted by staff or field personnel of VS or 

by other laboratories, institutions, or agencies. 

Reagent Evaluation – Tests conducted for the purpose of evaluating a reagent 

produced by other laboratories, institutions, or agencies. 

NVSL Intralab – Tests conducted for another laboratory of the NVSL. 

14. COUNTRY OF ORIGIN/DESTINATION

For import or pre-import cases, enter the country in which the animals last 

resided. For export cases, enter the country to which the animals will be 

shipped. 

15. REFERRAL NUMBER 

This number is typically assigned by the submitter and is used for the submitter’s 

own reference. In FAD cases, enter the investigation control number described 

in the instructions for Block 12. 

16. PRESERVATION 

Check all blocks that apply. 

17. SPECIMENS SUBMITTED “REQUIRED” 

Check all blocks that apply. 

18. TOTAL NUMBER OF SPECIMENS SUBMITTED

Enter the total number of specimens submitted. Specimens in one container are 

counted as one sample. Please limit to <250 samples per submission. 

19. SPECIES OR SOURCE “REQUIRED” 

Check only one block. If specimens are from different species or sources, use a 

separate VS Form 10-4 for each source. Reminder: Enter the animal BREED in 

Block 21. 

20. NUMBER OF ANIMALS SAMPLED

Enter the total number of animals sampled. 

21. IDENTIFICATION “REQUIRED” 

Sample ID – Identify samples with consecutive numbers. Ensure the sample 

identification number on this form matches the sample identification 

number placed on the specimen container. 

Animal ID – Record the animal’s national identification tag number adjacent to 

the appropriate sample number. If there is no national animal identification 

number, record the most appropriate identification number (or name). 

NOTE: Laboratory results will be reported by animal identification number. 

Breed – Enter the animal breed (e.g., Holstein, Angus). 

Age – Indicate the approximate age in years (y), months (m), weeks (w), or 

days (d). 

Sex – Indicate the sex, male (M) or female (F), for each animal. 

22. ADDITIONAL DATA

Enter all pertinent information about the animals and premises that can assist the 

lab in making a diagnosis. 

• Provide detail on tissue specimens you are including (e.g., lymph nodes, 

obex, brain). 

• Specify clinical signs (e.g., weight loss, hair missing). 

• If meat is being retained pending specimen results, enter RETAINED. 

• Add related case submission numbers to assist in trace activities. 

• Include any information that did not fit into its designated space 

elsewhere on the form. 

• Include any special (non-standard) instructions for test report delivery. 

23. SIGNATURE OF SUBMITTER AND DATE 

The individual submitting the specimen(s) must sign and date the form VS Form 10-4 (Reverse)