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Download DA Form 8014-R, also known as Cockroach Survey. This form is part of the U.S. Army’s pest surveillance program. This form is designed to collect information to determine the cockroach population inside each individual dwelling. This information will be supplied along with collection of cockroaches to determine species as well as other vital information. The efforts of the U.S. Army’s pest management program is designed to control disease agents carried by cockroaches and other pests. The answers to the sections contained in this form will be evaluated.

How To Fill-In

Step 1 – Cockroach Survey – Begin by completing  blocks 1 through 5 as follows:

  • 1. Building
  • 2. Organization
  • 3. Date
  • 4. Time
  • 5. Person Contacted (full name)

Step 2 – Part 1 – Mission of Structure – Complete blocks 6,7a and b., 8a. and b.:

  • 6. Mission of Stucture ( what is the building in question, used for, what is the purpose of the building)
  • 7. – Food Handling Facility -
  • a. Meals/Day
  • b. Days Open/Week
  • 8. – Quarters -
  • a. Single
  • b. Multiple Unit

Step 3 – Part 2 – Sanitation – Check appropriate boxes in blocks 9 and 10:

  • 9. Sanitary Conditions – Select and check the appropriate box
  • 10. a. through d. – address all of the conditions by using the drop down arrow inside each question box, select y or n.

Step 4 – Part 3 – Harborage – Answer sections 11 through 19 with the appropriate yes or no answer:

11. Harborage Conditions (check the appropriate box)

  • 12. Space Around Pipes Sealed (yes or no)
  • 13. Holes In Walls (yes or no)
  • 14. Serving Line (yes or no)
  • 15. Equipment (yes or no)
  • 16. Bar (yes or no)
  • 17. Crawl Space (yes or no)
  • 18. Attic (yes or no)
  • 19. Other- In this box place any information with regard to other locations where cockroaches may have populated inside of the establishment.

Step 5 – Part 4 – Cockroach Species – Answer questions 20. and in section 21. check appropriate boxes that would apply:

  • 20. Kind
  • 21. Observation – (check applicable boxes)

Step 6 – Part 5 – Sticky Trap Data – Answer 22.,23., 24. a., b., c., 25. and 26:

  • 22. Trap Number
  • 23. Location
  • 24. Number (fill in required information in column a., b., and c.)
  • 25. Comments – (enter any additional information that may be important)
  • 26. Comments- (space for any additional needed information

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