Tick Submission Form Date:
Instructions: Complete this form and include it with your tick specimen
(It is important to print information legibly).
Information on person/health department submitting tick (to whom report will be sent):
(Please identify name and e-mail address of the person/health department official to whom the
report will be sent.)
Name:
Address:
City: State: Zip Code:
E-mail Address (required): Telephone number(s):
Please note that the Tick Testing Program is intended for the identification and/or testing of ticks
which have fed on humans. Ticks removed from pets will be identified, but not tested.
Was this tick removed from a pet? Y N
Pet species/name/age:
Information on person bitten by tick:
Name (if different from above):
Address (if different from above):
Telephone number(s):
Age: Gender: M F
Date tick was removed: Part of body where tick was found:
Town in which tick was acquired:
Please submit samples to:
The Connecticut Agricultural Experiment Station, Tick-Testing Laboratory, Slate Building Room
112, 123 Huntington Street, P.O. Box 1106, New Haven, CT 06504
Phone: (203) 974-8500 Fax: (203) 974-8502
Toll Free: 1-(877) 855-2237
WWW.CT.GOV/CAES
An Affirmative Action/Equal Opportunity Employer
