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Dead/Ill Bird Report and Lab Submission - Department of Health (New Jersey) Mobile App

Information from this form should be entered into the web-based, secure WNV surveillance system by the agency submitting the specimen. The WNV surveillance system will generate a unique identifier called a USI. Vectorborne Disease Program staff will enter the information for you and contact you about getting access to the electronic surveillance system. Be sure to include your fax number so program staff can send you the USI to be submitted with the bird.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Dead/Ill Bird Report and Lab Submission - Department of Health (New Jersey) Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    Health Department Name:

  • Ico textbox

    County:

  • Ico textbox

    Name of Contact Person Submitting the Form:

  • Ico textbox

    Telephone Number:

  • Ico textbox

    Fax

  • Ico textbox

    Email Address

  • Ico date

    Date of Call:

  • Ico time

    Time of Call:

  • Ico textbox

    Name of Person Calling:

  • Ico textbox

    Telephone:

  • Ico multiline

    Pickup Address:

  • Ico date

    Date Bird Observed:

  • Ico multiline

    Location of the Bird (if different from Pickup Address):

  • Ico statictext

    Type of Bird:

  • Ico checkbox

    Crow

  • Ico checkbox

    Blue

  • Ico checkbox

    Jay

  • Ico checkbox

    Hawk

  • Ico textbox

    Other:

  • Ico date

    Date of Pickup:

  • Ico dropdown

    Was the bird submitted for testing?

  • Ico statictext

    Instructions for Sending Specimen

  • Ico checkbox

    submitting the specimen.

  • Ico statictext

    Place bird into a one-gallon, clear, Ziploc bag.

  • Ico statictext

    http://www.

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  • Creator: Team GoCanvas
  • Language: English
  • Country: United States of America
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