Source: http://www.ent3.orst.edu/smartkey/sample_sub_form.htm Sample Submission Form Extension Entomology Insect Clinic Department of Entomology Oregon State University 2046 Cordley Hall Corvallis, OR 97331-2907 541-737-5520 Fax: 541-737-3643 internet: entoffice@bcc.orst.edu
commercial ____ Office Use: noncommercial ____ Date rec'vd_______Sample #______
Client : Name___________________________ Agent: Name__________________ Address_________________________________ Address______________________ ________________________________________ _____________________ phone __________________________________ phone________________________ county______________ Data date collected__________ collection location________________________________ _____________________________________________________________________________ _____________________________________________________________________________
Crop/Garden __yard/landscape __nursery (__container __field) __field crop __golf course/sod farm __Christmas tree plantation __orchard __lawn __greenhouse __vegetable garden other______________________________________________________________________
Additional Information: Host plant + variety_________________________________ part of plant affected_________________field size/plant numbers______________ field rotated from__________________________ pattern of damage_______________ other comments_______________________________________________________________
Medical/Veterinary Host/patient__________________age______ location on host_____________________ symptoms_______________________________________________________________________________ association with other animals (specify)_____________________________________ recent travel or known geographic location of first contact__________________ other________________________________________________________________________
Home where in home________________________________________________________________ type of product affected (if in wood, be as specific as possible)____________ kind of damage (include shape and size of exit holes, frass etc.)____________ other________________________________________________________________________
Diagnosis and Information Determination (order:family,genus species) _________________________________ common name (if any)_________________________________________________________ comments Extension Specialist_________________________________date____________