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HPAI Poultry Owner Report Form - Boulder01 Control Areas
Poultry owners: Please fill out this form to report poultry on your premises
Propietarios de aves de corral: complete este formulario para autoinformar las aves de corral en su establecimiento
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* Indicates required question
Name/nombre:
*
Your answer
Phone number/número de teléfono:
*
Your answer
Email address/dirección de correo electrónico:
Your answer
Address of poultry/dirección de aves de corral:
*
Your answer
Mailing address/Dirección de envio:
*
Your answer
Total number of poultry/número total de aves de corral:
Your answer
Species of poultry (chicken, duck, turkey, etc)/especies (pollo, pato, pavo):
Your answer
Have any of the birds been sick? /¿Alguno de los pájaros ha estado enfermo?
*
Yes
No
Have any of the birds died?/ ¿Ha muerto alguno de los pájaros?
*
Yes
No
Please explain any sick or dead birds/Por favor explique cualquier pájaro enfermo o muerto
Your answer
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