Instructions for completing VS Form 10-11 (version DEC 2020)

(Completion of Fields 2 - 24 is required; if none, line through box fully or write “none”)

Field 1: Accession Number 
Leave blank.

Field 2: Date Blood Drawn 
Indicate the date the veterinarian obtained the sample from the animal. This is the official test date.

Field 3: Test Requested by Veterinarian 
The veterinarian determines which test should be run by the laboratory - based on the reason for the testing.

Field 4: Reason for Testing 
If more than one option applies, mark the most compelling reason for performing the test.

• Interstate Movement = movement between States.
• Within State Use/Annual = movement within a State (intrastate), shows/events, or any annual or routine testing.
• Change Ownership/Sale = includes tests run for private sales, markets or auctions whether required by state law or otherwise.
• International Import/Export = international movement into or out of the USA.
• Illness/Clinical Suspect = diagnostic testing of sick animals.
• Investigation/Exposure = official investigations by authorities.

Field(s) 5: Name & Mailing Address of Owner
May be a market or auction. This section was designed for use in a window envelope. For best results you should use ALL CAPS, dark ink, print clearly and follow USPS guidance.

Field 6: County of Current Home Premises of Equine
The county of the current home premises equine residence in Field 7.

Field(s) 7: Current Home Premises of Equine
Physical address of the current home premises or residence of the animal. This includes farms, stables or racetracks - where the animal normally lives. It may include a market location if the home premises is unknown. It should NOT include a temporary location such as a veterinary clinic. DO NOT use a Post Office Box.

Field 8a: Veterinarian Name
Name of veterinarian who drew sample. DO NOT enter a practice name.

Field 8b: Veterinarian National Accreditation Number
National Veterinary Accreditation Number of Cat II accredited veterinarian who drew the blood sample.

Field 8c: State in Which the Blood Sample Was Obtained
Use the 2 letter code for the State in which the blood sample was obtained.

Field 8d: Veterinarian Signature
Signature of the accredited veterinarian who drew the blood sample.

Field 8e: Signature Date 
The date the veterinarian signed the form.

Fields 8f, g, h, I, j: Mailing address & Phone Number of Veterinarian
Mailing address and phone number of veterinarian.

Field 9: Tube Number (#) 
If applicable, per accredited veterinarian.

Field 10: Name of Animal

If the animal does not have a name enter NONE however, a unique identifying number associated with the animal will be required in Field 16, 17 or 18.

Field 11: Color 
Enter coat or hair color(s).

Field 12: Breed of Horse (or species of equid)
Enter the horse’s breed(s). If equid is not a horse enter the species. Ex: donkey, mule, hinny or zebra.

Field 13: Sex 
Check the box to indicate sex.

Field 14: Age or DOB
Record the animal’s age (XX) in years (Y); use months (M) if less than one year (Example: 01Y or 12M) or indicate the date of birth: MM/DD/YYYY.

Field 15: Tag Number (#) 
Any tag number used for ID. If none enter NONE.

Field 16: Tattoo Number (#) 
Enter tattoo number. If none enter NONE.

Field 17: Microchip Number (#)
Enter the microchip number or NONE DETECTED.

Field 18: Breed Registration Number (#) 
Enter number, NONE or UNKNOWN

Silhouette/Line drawing

• Instructions: This section, while not required, complements the required narrative descriptions in Fields 19 – 24. Show, draw or otherwise represent all permanent white markings, brands, tattoos, and scars. Mark whorls with an X. The animal should be uniquely identified. Non-descript animals require greater detail; use whorls and scars to properly identify the animal. Brands should be drawn.

Fields 19 - 24: Head, Neck & Body, Left Forelimb, Right Forelimb, Left Hindlimb, Right Hindlimb

• The narrative description is required; indicate all permanent white markings, brands, tattoos, scars, & whorls. Blank fields are not acceptable - if none line through box fully or enter “NONE”. The animal should be uniquely identified. Nondescript animals require greater detail; use whorls and scars to properly identify. For the head suggested nomenclature includes any combination of star, strip, snip, lip, chin, blaze, bald; modified by “connected” if applicable. For limb markings describe the most proximal extent of the white area. Suggested nomenclature includes none, heel, coronet, pastern, fetlock, cannon, carpus/hock, above carpus/hock.

Fields 25 - 32: For Laboratory Use Only: Leave blank