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____________