| Submission Information |
| Type of sample |
Check the box indicating whether a physical sample specimen is being delivered to an NDA office or if a photo of the specimen sample will be emailed or texted. |
| Sample origin |
This section is for inspectors to complete only. Inspectors should check all boxes that apply to the origin of the sample. |
| Submitter reference ID |
Please enter an ID for your reference as applicable. This field is not required. |
| Date collected* |
Enter the date the sample was collected. Please reference https:// agri.nv.gov/Plant/Entomology/Shipping for proper preservation of samples. This field is required. |
| Property owner/Business name |
Enter the name of the property owner or the business where the sample was collected. |
| Collection address* |
Enter the number, street name and unit (as applicable) of the address where the sample was collected. Example: 1235 S. Elm St. #53 |
| City* |
Enter the city where the sample was collected. This field is required. |
| County* |
Enter the county where the sample was collected. This field is required. |
| Collector Information |
| Collector 1 name* |
Enter the first and last name of the individual collecting specimen. This field is required. |
| Collector 2 name |
If additional individuals were collecting specimen, please include their first and last name. |
| Collector name |
If additional individuals were collecting specimen, please include their first and last name. |
| Collector affiliation |
Check the box indicating if the collector is affiliated with State, County, Federal, PCO or Other programs. |
| Collector’s mailing address* |
Enter the mailing address for the collector. This is where a report will be sent if an email address is not provided. This field is required. |
| Collector email* |
Enter the collector’s email address. The report will be emailed to this address. This field is required. |
| Contact phone number* |
Enter the collector’s phone number for use if additional information is needed. This field is required. |
| Sample Information |
| Type of insect |
Enter a description of what type of insect this is. Example: Beetle, fly, etc. |
| Specimen status |
Check the box indicating whether the specimen was alive, dead or trapped. |
| Host* |
Enter information about where the insect was found and/or what it was on. This field is required. |
| Insect life stage |
Check the box indicating if the specimen is an egg, larva, nymph, pupa, or adult (if known). This field is not required. |
| Infestation |
| Single specimen |
If only one specimen was found, check this box and skip to the next section. |
| # per leaf |
Enter the number of specimen found on a single leaf. |
| # per fruit |
Enter the number of specimen found on a single fruit. |
| # per square yard |
Enter the number of specimen found in a single square yard. |
| # per stem |
Enter the number of specimen found on a single stem. |
| # per sweep |
Enter the number of specimen found in a sweep. |
| # per linear feet |
Enter the number of specimen found in a linear foot. |
| # per limb |
Enter the number of specimen found on a single limb. |
| # per trap |
Enter the number of specimen found in a single trap. |
| # per animal |
Enter the number of specimen found on a single animal. |
| Other |
If you have another measurement indicating the number of insects, please include it here. |
| Damage |
| Check extent of damage. |
Check the box indicating how extensive the damage caused by the specimen is. |
| Check level of damage to host. |
Check the box indicating how much damage the specimen caused to the host was. |
| Number of acres infested |
Write in the number of acres that were affected by the specimen |
| Quarantine information |
| This section is for inspector use only. If you are not an inspector, you may proceed to submitting the form. |
| Consignee |
Inspectors should enter the name of the consignee |
| Contact name |
Enter the name of the contact. |
| Quarantine shipper |
Enter the name of the quarantine shipper. |
| Quarantine address |
Enter the name of the quarantine address |