PLANT DISEASE SAMPLE SUBMISSION FORM
Office Use Only:
Date received: __________
Sample #: ______________
PDIS #: _______________
Account #: _____________
UMD Plant Diagnostic Laboratory
3171 Plant Sciences Building
4291 Fieldhouse Drive
College Park, MD 20742-4454
301-405-1611 FAX: 301-314-9290
extension.umd.edu/plantdiagnosticlab
Submitter’s Name ___________________________
Business ____________________________________
Address _____________________________________
City/State/Zip _______________________________
County _____________________________________
Phone ______________________________________
Email ______________________________________
Fax ________________________________________
Grower’s Name _______________________________
Business _____________________________________
Address _____________________________________
City/State/Zip _________________________________
County ______________________________________
Phone _______________________________________
Email ______________________________________
Fax ________________________________________
Information about Submitter/Grower: Please check one each for submitter (S) and grower (G)
S
G
Extension Educator
S
G
Golf Course
Lawn/Tree Care Co.
S
G
S
G
Homeowner
S
G
Consultant
Garden Center
S
G
S
G
Farmer
Greenhouse
Other ____________
S
G
S
G
Dealer/Industry Rep
Nursery
S
G
S
G
SEND REPLY TO:
Submitter
By:
Mail
Fax
Grower
Email
Plant: _____________________________ Cultivar: ______________ Date sample collected: __________
Plant location:
Yard/Landscape
Lawn
Golf Course
Vegetable garden
Field/Farm
Greenhouse
Nursery
Orchard
Other ________________
Date planted: _________________
Size of planting: ________________
% of plants affected:_____________
Distribution of Affected
Plants:
Single plant
Scattered
Grouped
Approximate age: _____ Number of years at present site: _____ Date first noticed problem: ______________
Exposure:
Full sun
Partial shade
Full shade
Windy
Protected
Root disturbance from:
sidewalks/driveway
construction activities (describe): _____________________
Irrigation frequency and type: _________________________________________________________________
Tillage practices: __________________________________________ Previous crop: ____________________
Chemicals/fertilizers applied (past 2 years; include rates): ___________________________________________
__________________________________________________________________________________________
Soil type:
sandy
clay
silt
loam
organic
Soil pH: ___________
Drainage:
tends to be dry
moist, but drains well
water collects
DESCRIBE THE PROBLEM (Include symptoms, plant parts affected, etc. Attach separate sheet if necessary):
Your tentative diagnosis: ___________________________________________________________________