AFLB0001 (2018/05)

Surveillance Program Ticks on Companion Animals

Agri-Food Laboratories Submission Form

Personal information is collected for the purpose of managing and administering animal health surveillance for ticks in Alberta. Collection is authorized under section 33(a) of the Freedom of Information and Protection of Privacy (FOIP) Act and managed and protected in accordance with the Act. Questions about the collection can be directed to Director, Agri-Food Labs, 5th Floor O.S. Longman Building, 6909-116 Street, Edmonton, AB T6H 4P2 or at 780-422-4830

Clinic InformationClinic Veterinarian (include First and Last name)

Address City Province Postal Code

Telephone Number Email Address

Pet and Tick InformationPet Name (include First and Last name) Pet Type

Dog Cat OtherAddress City Province Postal Code

Date Tick(s) Collected (yyyy-mm-dd) Tick(s) attached to skin?Yes No Unknown

Pet Travel HistoryOut of Alberta in the last 2 weeks?

No Unknown Yes, provide locationOut of town, but still in Alberta, in the last 2 weeks?

No Unknown Yes, provide location

If No Travel: Indicate all outdoor locations that the pet has been in the last 2 weeks. Please give specific locations (including municipality) as this will help us determine where to target surveillance (e.g. name of park, major intersections, ravine or neighbourhood walk, entry/exit points to river valley, side of river visited, area of park visited such as NE corner.)

Provide outdoor locations visited by the pet in the last 2 weeks

Instructions for Submitting a Samplen Only veterinarians and veterinary clinics in Alberta may submit samples. For ticks from humans, contact your local Public Health

Clinic. Testing is free of charge. Samples can be submitted year-round.n Shipping costs may be covered. Prior to shipping, contact the Agri-Food Laboratories at 780-422-4830 for details. n Place ticks from separate animals in separate containers. Complete one submission form per animal.n Ship ticks in sealed containers and packaging that can withstand shipping. Do not freeze or add holes or needles or fixatives to the

container.n Ship to: Agri-Food Laboratories, Parasitology Laboratory, 6909-116 Street, Edmonton, Alberta, T6H 4P2.

Date Shipped (yyyy-mm-dd) Submitter's SignatureSubmitter's Name (PRINT)

AFL Use OnlyDate received (yyyy-mm-dd) Submission Number