TELEPHONE SURVEY

DATE OF REPORT:
 
Person Reporting Dead/Ill Bird:
Name:
Agency:
Address:
 
City:
State Zip:
Phone:  
Specimen Information:
Species:
Symptoms:
Condition:
Number of Affected Birds:
   
   
 
Collection Information:
Location:
Address:
 
City:
State: Zip:
County:
Notes/Comments/Additional Information
Longitude:
Latitude:
   
Other Area Description
 
Entered Date: Initials: