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 _____________________________________________________________________