Highly Pathogenic Avian Influenza (HPAI) Poultry Owner Self- Reporting Form

First Name *

Last Name *

Street Address *

City *

State *

County *

Zip Code *

Phone Number *

Email Address

Do you have any birds currently exhibiting these symptoms? *

Respiratory problems ( coughing, sneezing, nasal discharge)

Lack of energy or appetite

Decreased water consumption

Decreased egg production and/or soft-shelled, misshapen eggs

None of the above

Do you have any current concerns on the health of your birds? *

Yes

No

What kind of birds do you raise? *

Current Number of Birds (ex. 12 chickens, 5 ducks, 10 turkeys) *

Do wild waterfowl have access to areas where your birds are kept? *

Are eggs or poultry sold off the farm? *

When is the best time to reach you to follow up? *

Do any of your neighbors have any birds? If yes, please provide their phone number and address so we can inform them. *

Comments:

Thank you for submitting your information. We appreciate your diligence in protecting the poultry industry. Please remember this is not a human health concern and all poultry products are safe.

If any of your birds do become sick please give us a call back at 1-833-765-2006.