Tick Identification And Testing Form
Download a blank fillable Tick Identification And Testing Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Tick Identification And Testing Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Rev 01/16
Michigan Department of Agriculture and Rural Development
Pesticide and Plant Pest Management Division
Insect and Rodent Management Program
P.O. Box 30017, Lansing, MI 48909
(517) 284-5658
TICK IDENTIFICATION AND TESTING FORM
1.
If the tick is removed from a person, is received alive, and is of an appropriate species, it will be
tested by the MDCH-Laboratory for Lyme disease at no cost to the submitter.
2.
Place the live tick in a vial or small pill bottle and add a blade of grass or small (1-inch square)
piece of paper towel moistened with one drop of water. Be sure the cover is firmly secured on
the container with no air holes.
3.
To submit a dead tick for identification only, place it in a bottle with a small piece of paper towel
moistened with one drop of water or alcohol.
4.
Print or type information requested below and return this form with the tick in a container to the
above address. On the outside of the shipping container write “FRAGILE” or “HANDLE WITH
CARE” to help prevent damage to the tick when shipped.
Please indicate (check) if tick was found on:
E. If tick was found on a PERSON, please
A.
Person
Animal
Other
complete this section:
Patient’s Name: _________________________
Animal Type: ___________________________
Other (explain):__________________________
Age: ________ Sex: ________
______________________________________
Address: _______________________________
______________________________________
City: __________________________________
State: _____________
Zip: ____________
B. If tick was found on person/animal was tick
F. Send RESULTS to (if different from patient):
attached?
Yes
No
Mail
Email at ______________________
C. Date tick was collected: ___________________
Name: ________________________________
D. Location where tick exposure probably occurred:
Address: ______________________________
County: ________________________________
City: __________________________________
Township: ______________________________
State: _____________
Zip: __________
Telephone No.: _________________________
Check if you are willing to pay the Michigan State University, Diagnostic Center for Population and
Animal Health (MSU-DCPAH) a $60.00 fee for disease screening of your tick submission that was removed
off a host other than a human. Testing used is a Polymerase Chain Reaction (PCR) test to detect the
presence or absence of organism-specific DNA and are performed based on the type of tick submitted. Up
to five different PCR screening (B. burgdorferi PCR, R. rickettsia PCR, Babesia sp. PCR, Anaplasma PCR,
Ehrlichia canis PCR) procedures could be performed on a single tick submission. A personal check made
out to MSU-DCPAH for $60.00 must be included by the submitter for this screening service.
DO NOT WRITE BELOW THIS LINE
MDARD SAMPLE #: ____________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Aml 1 - Movement Document Under The Sheep And Goats (records, Identification And Movement) (england) Order 2009
Legal
Form Mi-273 - Application For Seafarer's Identification And Record Book And Special Qualifications
Business
Form W-9 - State Of Arizona Substitute W-9 Form Request For Taxpayer Identification And Certification
Financial
Related Categories
Parent category: Business