Avian PME
Submission Form
WVSC No:
Date received:
PLEASE COMPLETE ALL SECTIONS
CLIENT’S NAME AND ADDRESS
PRACTICE
Address where animals kept, if different from above
Clinician:
CPHH No.
Your reference:
Flock code (if applicable):
BIRD DETAILS
Please specify:
SPECIES: Chicken
Turkey
Duck
Goose
Pheasant
BREED/STRAIN: Please specify
Partridge
SEX: Male
Other
Female
Mixed
Unknown
N/A
PURPOSE – Please enter the main enterprise under which the affected birds are kept
Organic production
Yes
Breeder/parent – Layer
Breeder/parent – Meat
TYPE OF HOUSING
No
Not known
Production – Layer
Production – Meat
Game
- Breeding
- Rearing
Pet/Backyard
- Breeding/Show
- Other
Wild
Captive or zoo
Other
Barn
Brooder rings
Commercial cages
Controlled
environment Climatic –
pen/building Deep litter
Free range
Perchery
Pole barn
Slats
Other
Unknown
REASON FOR SUBMISSION
Diagnostic
Is this the first sample from this case/outbreak Yes
Monitoring
Zoonoses Order
Other
No
Previous Lab. Refs:
(please state)
CLINICAL HISTORY
No. in flock
No. in affected
group
No. affected
including dead
DURATION OF CLINICAL SIGNS
AGE
0-3 days
4 days – 2 weeks
> 2 weeks
Age of birds placed
No. died
Unknown
N/A
WRITTEN CLINICAL HISTORY – Please also use Supplementary Clinical History Form
Age of birds now
Please complete age category box below
0-3 days
4-7 days
Adult
(>20 weeks)
Mixed
Immature
Unknown
CLINICAL SIGNS – Please rank in order of importance e.g.1 = main clinical sign
Wasting/poor condition
Abnormal faeces
Upper GIT signs
Vent/cloacal disorders
Recumbent
Lameness
Musc/skel – not lame
Nervous signs
Respiratory
Skin/feather
Found dead
Non specific clinicalsigns
Type and number of carcases – Please refer to current PME price list for details
Egg drop
Egg quality
Infertility/poor hatchability
Unknown
Healthy
N/A
Other
BIRD AND SAMPLE IDENTIFICATION
Date sample(s) taken:
Bird/sample ID
This form should be emailed to enquiries@wvsc.wales
Wales Veterinary Science Centre, Y Buarth, Aberystwyth SY23 1ND Tel: 01970 612374 www.wvsc.wales
Type and number of samples
www.cmc.cymru
Supplementary
Clinical History Form
ADDITIONAL CLINICAL HISTORY
If appropriate, please use this table to help describe the morbidity/mortality pattern.
Mortality
Culls
Total to date
Today
Yesterday
Day before
VACCINATION/TREATMENT
Medicated in last 7 days? YES
Medication details
ND @
NO
IB @ IBD @
Salmonella
@ Marek’s @
Other @
FLOCK DETAILS
Source of birds:
Homebred
Purchased
If imported, Date
Please specify: As eggs
Country
No. of birds in batch
1
Number of houses/pens on site
As poults/pullets
2
3
As day olds
Total no. of birds in flock
4
5
Poor
Uneven
6
Number of birds per house
Source of birds
Age of birds when sourced/placed
Age of birds in each house now
Age or date of depopulation
HUSBANDRY
Feeding:
Ad lib
Restricted
Feed type:
In feed inclusions:
Recent feed changes: Ad lib
Restricted
Appetite:
Same
Increased
Decreased
Weight gain:
Water:
Same
Increased
Decreased
Ventilation system: Natural
Lighting:
Natural
Artificial
(pattern and intensity)
Type and condition of litter:
Mechanical
Heating (please specify):
GAME BIRD SUBMISSIONS
Rearing pens
At grass
Release pens
This form should be emailed to enquiries@wvsc.wales
Released
On wire
Wales Veterinary Science Centre, Y Buarth, Aberystwyth SY23 1ND Tel: 01970 612374 www.wvsc.wales
www.cmc.cymru