Name _____________________________________________ Phone # ________________

Address ______________________________________________________________________

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 _______________

Please put specimen in a crush-proof container and mail to your local extension office or the Home & Garden Education Center, 1380 Storrs Road, U-115, Storrs, CT, O6269-4115.

Date Received ________/________/________

Diagnosis ________________________________________________________

By whom ________________________________________________________

Recommendations ___________________________________________________________________

___________________________________________________________________

Prepared by: Edmond L. Marrotte, Consumer Horticulturist, Home & Garden Education Center, Revised 7/98

This information was developed for conditions in the Northeast. Use in other geographical areas may be inappropriate.

The information in this material is for educational purposes. The recommendations contained are based on the best available knowledge at the time of printing. Any reference to commercial products, trade or brand names is for information only, and no endorsement or approval is intended. The Cooperative Extension system does not guarantee or warrant the standard of any product referenced or imply approval of the product to the exclusion of others which also may be available.All agrochemicals/pesticides listed are registered for suggested uses in accordance with federal and Connecticut state laws and regulations as of the date of printing. If the information does not agree with current labeling, follow the label instructions. The label is the law.Warning! Agrochemicals/pesticides are dangerous. Read and follow all instructions and safety precautions on labels. Carefully handle and store agrochemicals/pesticides in originally labeled containers immediately in a safe manner and place. Contact the Connecticut Department of Environmental Protection for current regulations.The user of this information assumes all risks for personal injury or property damage.Issued in furtherance of Cooperative Extension work, Acts of May 8 and June 30, 1914, in cooperation with the U.S. Department of Agriculture. Kirklyn M. Kerr, Director, Cooperative Extension System, The University of Connecticut, Storrs. The Connecticut Cooperative Extension System offers its programs to persons regardless of race, color, national origin, sex, age or disability and is an equal opportunity employer.