NEVADA DEPARTMENT OF AGRICULTURE
                           PLANT PATHOLOGY LABORATORY (PPL)
                                       ST
                           405 S. 21  STREET, SPARKS, NV 89431
                           plantpathology@agri.nv.gov
                                                                        PLANT SAMPLE SUBMISSION FORM
                                                                                                                                                    Sample Unique ID #:
                FULL NAME OF SENDER (Print clearly)                               DATE OF SUBMISSION                                          SENDER’S SAMPLE TRACKING NUMBER 
                                                                                                                                                       
               
              R EMAIL ADDRESS TO RECEIVE REPORT (Print clearly)                                                                               OTHER CONTACT INFORMATION
              E
              D          
              N                                                                                                                               Work Phone:       
              E
              S                                                                                                                               Home Phone:     
                MAILING ADDRESS (Print clearly)
                Street:                                                                                                                       Cellular Phone:             
                City/State/Zip:                                                                                                               Fax:            
                                GENERAL DIAGNOSIS                                           REGULATORY DIAGNOSIS                                                    LAB TEST & ID
                      Problem of House Plants                                           Nursery or Port of Entry Inspection                         Nematode Analysis
              E       Problem of Home Yard Plants and Trees                             P. ramorum Trace Forward                                    Genetic Modified Organism (GMO) Test
              C
              I       Problem of Plants in Nurseries                                    Seed Potato Certification                                   Specific Pathogen Test (Specify):          
              V
              R
              E       Problem of Plants in Commercial                                   Alfalfa Crop Inspection                                     Insect Identification (Do not use this form)
              S
                Landscape
                      Problem of Agricultural Crops                                     Allium Crop Inspection                                      Weed Identification (Do not use this form)
                      Problem of Forest Trees                                           Phytosanitary Inspection                                    Pesticide Analysis (Do not use this form)
                COMMON NAME OF PLANT                                   SCIENTIFIC NAME OF PLANT                                               APPROXIMATE AGE OF PLANT
                                                                                                                                                       
                     DAMAGE CHARACTERISTICS                            AFFECTED PLANT PARTS (“X” All Applicable)                                      PLANT SYMPTOM (“X” All Applicable)
                      Limited or isolated (few plants)                       Leaves                          Roots                                  Abnormal                        Dieback
              A                                                                                                                               Growth
              T       Edge of lawn or field                                  Petiole                         Bulbs, Tubes, Corms                                                    Fruit Rot
              A
              D                                                                                                                                     Leaf Blight
                      Scattered patches or circles                           Stem                            Buds                                                                   Galls
              T
              S                                                                                                                                     Leaf Chlorosis
              O       Entire tree or shrub affected                          Trunk, Bark                     Flowers                                                                Stunting
              H                                                                                                                                     Leaf Spot
                      All plants of same species affected                    Branches                        Blossoms                                                               Root Rot
                      Multiple plant species affected                        Growing Tips                    Fruits or Nuts                         Leaf Rust                       Wilt
                      Sudden damage or death (1-4                            Twigs                           Seeds                                  Stem Canker                     Sudden Death
                wks.)                                                        Frond                           Other                                  Stem Rust                       Other:          
                      Slowly progressive                                                                                                            Scorch or Burn
                             TYPE OF SAMPLE                                             LOCATION OF SAMPLE                                                    State Inspector Use Only
              E       Flower                     Bark                  County:                                        Longitude:              NURSERY/FIELD:      
              L                                  Root                  Street:                                                 
              P       Fruit                                                                                                                   REMARKS:      
              M                                  Soil                  City:                                          Latitude: 
              A
              S       Leaf                       Whole plant           Zip:                                                    
                      Branch                     Other
                     Twig
              E Irrigation Type:          Drip         Sprinkler           Overhead            Manual            No Irrigation           Never Checked              Don’t Know             N/A
              R Watering Frequency:               2 Days/Week              3 Days/Week              Everyday            Don’t Know             Other (Specify):          
              U
              T
              L Fertilization Frequency:              Every Month             Every 3-6 Months              Never           Don’t Know             Other (Specify):          
              U
              C Spray in Last 6 Months:               Insecticide          Herbicide            Fungicide           Bactericide           Other (Specify):          
                          USE OF DIAGNOSTIC REPORT                                                                               SENDER’S CATEGORY
              T      For My Information Only                                           Homeowner                                                 Farmer or Producer
              R
              O      For My Clients                                                    Nursery Employee                                          University of Nevada Cooperative Extension
              P
              E      For State and Federal Programs                                    Landscape Professional                                    State Inspector
              R
                     For an Insurance Claim                                            Pesticide Applicator                                      Federal Inspector
                     For a Legal Case                                                  Private Consultant or Arborist                            Other (Specify):          
                                                NDA-PPL-Form-012-001     Version 1.4    Approved by Quality Manger     Effective 07/05/2016
                                  Printed and downloaded copies are for reference only. Current version of document is maintained by NDA-PPL 
                                                                  © By PPL, Nevada Department of Agriculture. All rights reserved.
   DESCRIBE THE NATURE AND EXTENT OF THE PROBLEM:
            
                 NDA-PPL-Form-012-001     Version 1.4    Approved by Quality Manger     Effective 07/05/2016
            Printed and downloaded copies are for reference only. Current version of document is maintained by NDA-PPL 
                       © By PPL, Nevada Department of Agriculture. All rights reserved.