On what day? At what time?
Who picked it up? (specify name, age, occupation, place of residence)?
Where was it picked up? (in the rice field, or on a rooftop, on the top of the tree, under the water, on the water, etc.)
Do you see the enemy aircraft dropping it? (note yes or no)
How many, and what kinds of, samples are included with this form? (Example: 4 worms, 5 leaf tips, 7 leaflets with worms stuck to it, a white powder, etc.)