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
Imported Animal:
(please circle)
YES
NO
Age:
Feedlot
(yrs) (estimate of age, not CFA or aged)
Clinical history including treatment (if administered) and post mortem findings:
Provisional diagnosis:

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).

Submission of other tissue specimens is optional but should be done to support your provisional diagnosis.

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

Apprehension

Hyperaesthesia (sound, touch)

Ataxia

Behaviour change

Hypoaesthesia (sound, touch)

Paralysis/paresis

Temperament change

Head shyness

Fetlock knuckling

Abnormal ear position

Excessive licking/flank kicking

Falling

Nervous of entrance

Head rubbing or pressing

Tremor

Teeth grinding

Kicking when milked

Abnormal head carriage

Frenzy

Pruritus

Circling

Altered consciousness

Itching

Recumbency

Moribund (without infection/trauma)

Rubbing

Blindness

Wool loss (flank & hind qtr)
Name of submitter (AHO/Veterinarian): (PRINT)
Business name and address: (PRINT)
SUBMITTER SIGNATURE
DATE
1
Eligible 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
LABORATORY USE ONLY
Clinically consistent animal OR
Fallen (Dead) animal

Samples received in Good Order
YES / NO
OR
Casualty (Down) slaughter animal
NTSESP COORDINATOR SIGNATURE
DATE
Version: 10 February 2016