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:___________________________________________________________
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Phone:_____________________
Address:___________________________________________________________
___________________________________________________________
Phone:_____________________
Fax: _______________________
Email:_____________________
( ) homeowner ( ) grower ( ) landscaper/arborist ( ) other
( ) homeowner ( ) grower ( ) landscaper/arborist ( ) other
( ) Plant Identification
( ) Disease Diagnosis
( ) Weed Identification and Control
( ) Cultural Information: ( ) General ( ) Pruning ( ) Fertilizing
( ) Other __________________________________
______________________________________________________________________________ PLANT NAME: ______________________________ __________________________
scientific or common name cultivar or variety
______________________________________________________________________________ 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 | ( )______ |
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 |
|
Soil Type: | Drainage: | Watering: | |
( ) sandy | ( ) clay | ( ) good | ( ) never |
( ) loamy | ( ) mulch | ( ) fair | ( ) daily- morning |
( ) potting mix | ( ) poor | ( ) daily- evening | |
( )______ | ( )______ | ( )______ |
( ) none applied
( ) rate and date applied below
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______________________________________________________________________________ ______________________________________________________________________________ Notes:
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Action: _____________