GENERAL SUBMISSION / NECROPSY FORM · GENERAL SUBMISSION / NECROPSY FORM . DVM SPECIES # in Herd...
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GENERAL SUBMISSION / NECROPSY FORM DVM SPECIES # in Herd Address CHECK ANY THAT APPLY: HISTORY (include signs of suspect rabid animal if appropriate) Tentative Diagnosis Body Tissue (list) I request a complete diagnostic examination (at discretion of Laboratory) Bacteriology Clinic Address City State Zip Phone Fax Copy to Fax Phone Zip State City OWNER Age Sex # Dead Breed # Sick Diarrhea Pneumonia Abortion Serum Whole Blood Feces Fluid/Swab I request ONLY the following services/tests: Histopath Virology Molecular Diagnostics (PCR) Rabies Test Parasitology Serology Immunohistochemistry VSD.ADRDL.FORM.SPR.0001.03 Last Revised 3.10.11 Export to NO YES IS THIS A RABIES SUSPECT? State City Person(s) # OF SPECIMENS IF RABIES IS NEGATIVE DO YOU WANT A COMPLETE NECROPSY? YES NO Treatments Vaccinations Wildlife Stray Pet WAS THIS ANIMAL VACCINATED FOR RABIES? NO When? HUMAN EXPOSURE? Tox Exam (list specific toxin) Gross Necropsy Lesions YES This box is for client's internal use only. Date Accession Number South Dakota State University Animal Disease Research & Diagnostic Lab Box 2175, North Campus Drive Brookings, SD 57007 email: [email protected] 605.688.5171 605.688.6003 (fax) website: http://sdstate.edu/vs Lameness CNS Other DID THIS ANIMAL EXPOSE ANY OTHER ANIMALS TO RABIES? Type? YES NO This is not an official Federal test form. Use Laboratory VS Forms for Brucellosis and EIA.The ADRDL is an accredited AAVLD laboratory and a member of the USDA National Animal Health Laboratory Network. Completing and submitting any submission form or any other means of requesting services creates a contractual agreement for services requested and the specimens submitted become the property of the ADRDL. At no additional expense to our clients, specimens submitted to the ADRDL may be subjected to additional testing upon the order of state or federal animal health officials, or when a Foreign Animal Disease is suspected, or in support of surveillance for other animal diseases. Animal ID Number(s) Date Collected Premise ID State IF SWINE SIV SUBMISSION: Sick Pigs H1N1 Public Health Investigation Commingled Pigs
Transcript of GENERAL SUBMISSION / NECROPSY FORM · GENERAL SUBMISSION / NECROPSY FORM . DVM SPECIES # in Herd...
GENERAL SUBMISSION / NECROPSY FORM
DVM SPECIES # in Herd
Address
CHECK ANY THAT APPLY:
HISTORY (include signs of suspect rabid animal if appropriate)
Tentative Diagnosis
Body
Tissue (list)
I request a complete diagnostic examination (at discretion of Laboratory)
Bacteriology
Clinic
Address
City
State Zip
Phone Fax
Copy to
FaxPhone
ZipState
City
OWNER
Age Sex
# DeadBreed
# Sick
Diarrhea Pneumonia
Abortion
Serum Whole Blood Feces
Fluid/Swab
I request ONLY the following services/tests:
Histopath Virology Molecular Diagnostics (PCR)
Rabies Test ParasitologySerology
Immunohistochemistry
VSD.ADRDL.FORM.SPR.0001.03 Last Revised 3.10.11
Export toNO YESIS THIS A RABIES SUSPECT?
StateCity
Person(s)
# OF SPECIMENS
IF RABIES IS NEGATIVE DO YOU WANT A COMPLETE NECROPSY?
YESNO
Treatments
Vaccinations
WildlifeStrayPet
WAS THIS ANIMAL VACCINATED FOR RABIES?NO When?
HUMAN EXPOSURE?
Tox Exam (list specific toxin)
Gross Necropsy Lesions
YES
This box is for client's internal use only.
Date
Accession NumberSouth Dakota State University Animal Disease Research & Diagnostic Lab Box 2175, North Campus Drive Brookings, SD 57007 email: [email protected] 605.688.5171 605.688.6003 (fax) website: http://sdstate.edu/vs
Lameness
CNS Other
DID THIS ANIMAL EXPOSE ANY OTHER ANIMALS TO RABIES?
Type?YESNO
This is not an official Federal test form. Use Laboratory VS Forms for Brucellosis and EIA.The ADRDL is an accredited AAVLD laboratory and a member of the USDA National Animal Health Laboratory Network. Completing and submitting any submission form or any other means of requesting services creates a contractual agreement for services requested and the specimens submitted become the property of the ADRDL. At no additional expense to our clients, specimens submitted to the ADRDL may be subjected to additional testing upon the order of state or federal animal health officials, or when a Foreign Animal Disease is suspected, or in support of surveillance for other animal diseases.
Animal ID Number(s)
Date Collected
Premise ID State
IF SWINE SIV SUBMISSION:
Sick Pigs H1N1 Public Health Investigation
Commingled Pigs
