Animal disease form

This form may be used to notify the knowledge or suspicion of a notifiable animal disease under section 9 of the NSW Stock Diseases ACT 1923, or under section 7 of the Animal Diseases and Animal Pests (Emergency Outbreaks) Act 1991, or under section 22 of the Apiaries Act 1985.

*(denotes mandatory fields)

Person making notification details

Name
Address
Phone
Mobile
Email address
I am the owner of the property in which disease is being reported	No Yes
I am the owner of the animal/hive in which disease is being reported	No Yes

Name

Address

Phone

Mobile

Email address

I am the owner of the property in which disease is being reported

No Yes

I am the owner of the animal/hive in which disease is being reported

No Yes

Disease details

Disease name *
Species of animal/s affected
Date of onset of signs *
Number of animals/hives affected
Description of affected animals Note: breed, age, type, sex
Identification of affected animals Note: NLIS number (if tagged), brand, tattoo, earmark, beekeeper reg no

Disease name *

Species of animal/s affected

Date of onset of signs *

Number of animals/hives affected

Description of affected animals

Note: breed, age, type, sex

Identification of affected animals

Note: NLIS number (if tagged), brand, tattoo, earmark, beekeeper reg no

Property details

Property identification code Note: important to provide this if property has PIC
Address/location of affected animals

Property identification code

Note: important to provide this if property has PIC

Address/location of affected animals

Name of property owner
Address of property owner
Phone number of property owner
Mobile number of property owner

Name of property owner

Address of property owner

Phone number of property owner

Mobile number of property owner

Animal or hive owner details

Name of animal or hive owner
Address of animal or hive owner
Phone number of animal or hive owner
Mobile number of animal or hive owner

Name of animal or hive owner

Address of animal or hive owner

Phone number of animal or hive owner

Mobile number of animal or hive owner

Laboratory details

Laboratory test specimens were submitted to laboratory * Please select	Yes No

Laboratory test specimens were submitted to laboratory *

Please select

Laboratory name

Laboratory name