Purdue Plant Diagnostic Lab — Plant Submission Form

Fill out by hand and mail with your sample, or fill in on-screen and print.

Submitter Information

First name

Last name

Business / organization

Address

City

State

Zip

County

Phone

Plant Name

Cultivar Variety

Field Id

Date Planted

Approximate Age

Date First Noticed

Chemical Fertilizers

Problem Description

Tentative Diagnosis

Location (tick all that apply)

Landscape Greenhouse Nursery Field Other

If other, please specify

Distribution (tick one)

Scattered General Other

If other, please specify

Desired Information (tick all that apply)

Diseases Identification Insect Identification Plant Identification Other

If other, please specify

Sun Exposure (tick all that apply)

Full Sun Partial Sun Full Shade Unknown

Percent Affected (tick one)

<25% 25-50% 50-75% >75%

Mail this form along with your physical sample to the Purdue Plant Diagnostic Lab.

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