Name ______________________________________________________ Phone # ________________
Address ____________________________________________ E-Mail __________________________
City _____________________________________________ State _______ Zip ___________________
Information desired
Identification _____________________________ Control ___________________________
If it causes damage __________________________ Does it sting _____________________
Other ____________________________________________________________________
Describe problem or damage__________________________________________________
_________________________________________________________________________
_________________________________________________________________________Where was specimen found?
In home ________ What room(s) __________________________ Cellar ______ Attic ______
Does home have a fireplace? Yes ______ No ______ In what room(s) ____________________
In yard ______ lawn ______ tree _____shrub ______ flower ______
Other place ________________________________________________________________
Specific host (if possible) ______________________________________________________
On cat ______ on dog ______ on poultry ______ on livestock ______ other ________
Degree of infestation
One _______________ Several _______________ Hundreds _______________
Put the sample and diagnostic form in a padded envelope or sturdy box. Mark the package with your name, mailing address, and phone number. Mail packages to arrive on weekdays to the following address:
Home and Garden Education Center
1380 Storrs Road Unit 4115
Storrs, CT 06269-4115
Phone toll free: 1-877-486-6271 for more information
For Home and Garden Education Use
Date Received ________/________/________
Diagnosis ___________________________________________________________
By whom ____________________________________________________________
Recommendations _____________________________________________________________________
____________________________________________________________________________________