Sampling form

Sampling form:

Cabbage Stem Flea Beetle pyrethroid resistance and parasitization rate in the UK

For each sample submitted, complete a Sampling Form and include it with the sample.

DOWNLOAD THE SAMPLING FORM HERE

Sampling information
Sampler’s name
Contact telephone
Email
Address
Date sampled
Where-from		  harvest hopper/trailer  seed store  both other: ____________________________
Crop variety/ies of harvested sample
Sample Location (Farm address, if different, including nearest town)
Where did you find about this study?		Leaflet at Cereals/Groundswell Twitter Email Rothamsted webpage Other: ____________________________
Insecticide usage
Product	Rate		Date applied

Rothamsted sample ref (leave it blank)

Notes

Please provide here the number of the box containing the beetles collected in this field if sampling different fields.

Data use declaration: I understand that my answers will be used only for research purposes. I understand that my data will be treated as confidential, my answers will remain anonymous after analysis and that I will not be identifiable in the final written reports. My participation was voluntary and I give my permission to use the data collected for the purposes described.

Signed: _____________________________________ Date: _____________________