Connecticut State The Connecticut Agricultural Experiment Station

Inquiry Office, Sample Submission Form, Windsor


Sample Submission Form:  Plants
Valley Laboratory, Windsor

Send sample submission form to:
Inquiry Office
Valley Laboratory
The Connecticut Agricultural Experiment Station
153 Cook Hill Road, P.O. Box 248
Windsor, CT 06095
(860) 683-4977

Date:_____________________
Name: ____________________________________________________________     
Address:___________________________________________________________      
           ___________________________________________________________                 
Phone:_____________________
Fax: _______________________
Email:_____________________

(   ) homeowner   (   ) grower   (   ) landscaper/arborist   (   ) other
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SAMPLE FOR:
            (   )  Plant Identification
            (   )  Disease Diagnosis
            (   )  Weed Identification and Control
            (   )  Cultural Information:   (   )  General        (   )  Pruning        (   ) Fertilizing
            (   )  Other  __________________________________
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PLANT NAME:  ______________________________        __________________________
                                            scientific or common name                     cultivar or variety
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FOR PLANT DISEASES:
Description of problem:
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Symptoms:                                                                                            Plant Part(s) Affected:
(   ) wilting
(   ) leaf spot
(   ) yellowing
(   ) stems
(   ) flowers
(   ) blight
(   ) streak
(   ) leaf drop
(   ) roots
(   ) fruit
(   ) galls
(   ) mosaic
(   ) marginal burn
(   ) leaves
(   ) entire plant
(   ) rot
(  )other:______

Distribution of Problem:                                                                Nature of Planting:
(   ) entire planting
(   ) edge of planting
(   ) field
(   ) nursery
(   ) random
(   ) low areas
(   ) yard
(   ) orchard
(   ) wet areas
(   ) high areas
(   ) forest
(   ) greenhouse
(   ) dry areas
(   ) sunny areas
(   ) indoors
(   )______
(   ) shaded areas
(   )______
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Age of Plants or Planting:

[time in the landscape or when planted or moved]

 

For NEW Plantings- Type of Stock:

(   ) 1-6 months

(   ) container-grown

(   ) 6 months-1 year

(   ) balled and burlapped

(   ) 1-3 years

(   ) direct seeded

(   ) 3-5 years

 

(   ) more than 5 years

 

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Soil Type:
Drainage:
Watering:
(   ) sandy
(   ) clay
(   ) good
(   ) never
(   ) loamy
(   ) mulch
(   ) fair
(   ) daily- morning
(   ) potting mix
(   ) poor
(   ) daily- evening
(   )______
(   )______
(   )______
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Chemicals and Fertilizers:
(   )  none applied
(   )  rate and date applied below
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Notes:
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                                                                          Action:  _____________