Contact Information  
Name - ex.(Lastname, Firstname)   
Email Ex.(johnDoe@site.com)   
Date - ex.(01/01/2002)   
City   
State   
Zipcode - ex.(39212-1700)   
Phone - ex.(601-333-3333)   
                                            Dead Bird(s) Location Information  
County   
Address   
City   
Zipcode - ex.(39212-1700)   
                                                     Dead Bird(s) Information  
Death Date Of Birds(s) ex.(01/01/2002)   
Number Dead   
Bird Species   
Did you see the bird(s) die?   
Did bird(s) show any neurologic symptoms?