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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 0579-0007. The time required 

to complete this information collection is estimated to average .16 hours 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 

0579-0007 

EXP: 08/2026

UNITED STATES DEPARTMENT OF AGRICULTURE 

ANIMAL AND PLANT HEALTH INSPECTION SERVICE 

NATIONAL VETERINARY SERVICES LABORATORIES 

AMES, IA 50010 

REQUEST FOR SALMONELLA SEROTYPING 

1. SUBMITTER (business name and name of individual contact) 2. NVSL SUBMITTER ID 3. HERD/FLOCK OWNER 

EMAIL ADDRESS 

PHONE NO. FAX NO. 

SUBMITTER ADDRESS (street, city, state, ZIP code) 

OWNER CITY & STATE 

PREMISES ID 

4. EXAMINATIONS REQUESTED 

SEROTYPING PHAGETYPING PFGE SE RULE OUT OTHER (specify in Block 15) 

5. NATIONAL POULTRY 

IMPROVEMENT PLAN 

(NPIP) YES 

6. ACCESSION/REFERRAL 

NUMBER

7. PAYMENT METHOD 

USER FEE ACCOUNT NUMBER CHECK/MONEY ORDER CREDIT CARD (number and expiration date) 

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

8. SPECIES OR SOURCE 

Cattle Goat Chicken Zoo (specify) Food (specify) Other (specify) 

Swine Horse Turkey Wildlife (specify) Foodstuffs 

Sheep Reptile (specify) Other Bird (specify) Environment (specify) Egg Pool Additional Description / Specification: 

9. CLINICAL ROLE 

INFECTION MONITOR/ENVIRONMENT RESEARCH OTHER (specify) 

10. SPECIMEN CULTURED 11. CULTURE NO. 12. O GROUP 13. SEROTYPE 14. PHAGE TYPE 

A. 

B. 

C. 

D. 

E. 

F. 

G. 

H. 

I. 

J. 

15. COMMENTS / SPECIAL INSTRUCTIONS

16. SUBMITTED BY (name and title) 17. DATE SUBMITTED 

NVSL ACCESSION NO 

SEROTYPED BY: 

(NVSL USE ONLY) 

VS FORM 10-3 

OCT 2009 
VS FORM 10-3 INSTRUCTIONS 

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

1. SUBMITTER CONTACT INFORMATION 

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 we 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 your results. Repeat submitters are encouraged to be consistent with the submitter contact information that they provide, as 

the NVSL keeps a master record. If the test report for an individual submission needs to be routed to a non-standard destination, clearly indicate special 

instructions. 

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) 337-7514. 

3. OWNER INFORMATION 

Enter the complete name, city, and state of the herd/flock owner. Ensure the animal owner is identified here and not the property manager or veterinarian. If a 

National Animal Identification System premises ID number has been assigned to the location of the animals, it may be entered. 

4. EXAMINATIONS REQUESTED 

Indicate the type of examination requested. 

5. NATIONAL POULTRY IMPROVEMENT PLAN 

Check the indicated box if the samples are being submitted as part of the National Poultry Improvement Plan (NPIP). 

6. ACCESSION/REFERRAL NUMBER 

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

7. PAYMENT METHOD 

If the requested testing is billable, 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. 

8. SPECIES OR SOURCE 

Check only one block. If specimens are from different species or sources, use a separate VS Form 10-3 for each source. Space is provided at the right side of this 

field to add detailed information when a general source category is selected and additional specification is requested. 

9. CLINICAL ROLE 

10.SPECIMEN CULTURED 

Enter the specimen/tissue from which the culture was derived. 

11.CULTURE NUMBER 

Ensure that the identification entered here exactly matches the number placed on the culture container. 

12-14. O GROUP, SEROTYPE, and PHAGE TYPE 

For NVSL use only. 

15. COMMENTS/SPECIAL INSTRUCTIONS: Use this space to enter any special instructions, including non-standard delivery of the testreport. 

16. SUBMITTED BY and 17. DATE SUBMITTED 

The individual submitting the culture(s) must sign and date the form.