National TSE Surveillance Program

F14.109

CLINICAL HISTORY AND NECROPSY REPORT

Date examined: / Owner/manager:
PIC: /
/ Property Address:
NLIS or RFID Number: /
/ Lab Specimen No.
Home bred? Yes ¨ No ¨
BOVINE / OR
(circle) / OVINE
Enterprise Type:
(please circle) / Meat / Milk / Fibre / Feedlot
Imported Animal:
(please circle) / YES / NO / Age: / (yrs) (estimate of age, not CFA or aged)

Clinical history including treatment (if administered) and post mortem findings:

Provisional diagnosis:

q  Essential specimens to submit are (A) unfixed, frozen cervical spinal cord (2 – 3 cm) and (B) whole, undistorted brain (preferably fixed) and fresh dorsal third of cerebellum (sheep only).

q  Submission of other tissue specimens is optional but should be done to support your provisional diagnosis.

q  Not more than 2 animals per disease outbreak are eligible for payment.

Tick the relevant boxes below that describe neurological and behavioural changes consistent with BSE or scrapie shown by this case 1

Mental Status / Sensation / Posture/Movement
q  Apprehension / q  Hyperaesthesia (sound, touch) / q  Ataxia
q  Behaviour change / q  Hypoaesthesia (sound, touch) / q  Paralysis/paresis
q  Temperament change / q  Head shyness / q  Fetlock knuckling
q  Abnormal ear position / q  Excessive licking/flank kicking / q  Falling
q  Nervous of entrance / q  Head rubbing or pressing / q  Tremor
q  Teeth grinding / q  Kicking when milked / q  Abnormal head carriage
q  Frenzy / q  Pruritus / q  Circling
q  Altered consciousness / q  Itching / q  Recumbency
q  Moribund (without infection/trauma) / q  Rubbing
q  Blindness / q  Wool loss (flank & hind qtr)
Name of submitter (AHO/Veterinarian): (PRINT)
Business name and address: (PRINT)
SUBMITTER SIGNATURE DATE

1Eligible cattle are older than 30 months of age but less than 9 years, that display at least two (2) behavioural changes or neurological signs without evidence of infectious disease.

Eligible sheep are 18 months of age or more (but preferably not more than 5 years) that display at least two (2) clinical signs compatible with scrapie.

NOTE: Incentives are not paid where:
·  an inappropriate report or specimens are submitted
·  the animal does not meet eligibility criteria
OFFICE USE ONLY
Clinically consistent animal ¨ OR / LABORATORY USE ONLY
Samples received in Good Order YES / NO
Fallen (Dead) animal ¨ OR
Casualty (Down) slaughter animal ¨
NTSESP COORDINATOR SIGNATURE DATE

Version: 26 March 2014