Poultry Avian Influenza Incident Form
1. Location Information
Farm Name
Farm Address
City
State/Province
Postal Code
Country
2. Contact Person
Full Name
Phone Number
Email Address
3. Flock Details
Poultry Species
Number of Birds
Average Age of Birds
Production Type
Broiler
Layer
Breeder
Backyard
Other
4. Incident Information
Date of Onset
Clinical Signs Observed
Number of Mortalities
Actions Taken
5. Additional Information
Comments