In-Vivo Animal Core (IVAC) Animal Diagnostic Laboratory General Submission Form Sample Drop-off Locations: IVAC Use Only

Monday – Friday, 9:00 AM – 3:00 PM 018 Animal Research Facility 1150 W. Medical Center Drive Ann Arbor, MI 48109-0614 ARF Phone: (734) 936-3803 IVAC Manager: (734) 647-0731

Monday – Friday, 9:00 AM – 4:00 PM North Campus Research Complex 2800 Plymouth Road B10/G90 Ann Arbor, MI 48109-2800 NCRC Phone: (734) 936-3395 Email: ulam-ivaclab@umich.edu

Date In: Date Out: Accession #:

Technician:

Short Code: Investigator: Department:

Lab Contact: Phone: Email:

Animal ID and # of Samples: Species: Animal Location:

Any experimental treatments that could affect results: Potentially Biohazardous Sample: Yes No

Potentially Infectious Sample: Yes No

If this is a mouse project, is it related to metabolic disease? v Yes No (check one)

Do you have a Mouse Metabolic Phenotyping Center (MMPC) order number? v Yes (please include number here) ______________________ No

v Mouse projects related to metabolic disease may qualify for support from the NIH MMPC Grant. Visit mmpc.med.umich.edu to complete an MMPC order request. The MMPC order number can be added to this form or provided while work is in progress. v

Animal Clinical Number: Submitted By:

Clinician: Resident: Vet Tech:

Clinical Summary / Differential Diagnosis:

Hematology: MUST be collected in EDTA purple top tubes

Blood smear (prep only) CBC, with automated differential Data in Excel format? Yes No (check one) 1 chemistry/animal ** 30 uL Hematocrit, spun 2 chemistries/animal ** 50 uL Manual Differential 3 chemistries/animal Reticulocyte count 4 chemistries/animal

Urinalysis: Please specify collection method 5 chemistries/animal Complete Urinalysis: (Routine Urinalysis, Casts per LPF, Bacteria, Mucous, Epithelial Cells, Crystals)

Any additional chemistries/animal

Routine Urinalysis: (Color/Clarity, Specific Gravity by refractometer, pH, Protein, Glucose, Ketones, Urobiligen, Bilirubin, Blood, RBC per HPF, WBC per HPF)

Electrolytes (ISE Na, K, CI) ** 150 uL

Parasitology Liver Panel: (ALT, AST, ALP, TBili, ALB) ** 100 uL Ceca Exam: Mouse Pig Liver Panel: (AST, ALP, TBili, ALB) Ceca Exam: Rat Renal Panel: (BUN, Creat) ** 50 uL Direct Smear for parasite or bacteria (check one) Mini Liver Panel: (ALT, AST) ** 50 uL Ectoparasite Exam (Tape, Pelt, or Slide) Mini Chemistry Panel: (ALB, ALP, ALT, Ca, BUN, Creat, T Prot, Gluc, TBili) ** 120 uL Fecal Flotation Pig Mini Panel: (ALB, ALP, Ca, BUN, Creat, T, Prot, Gluc, TBili) Fecal Occult Blood Full Chemistry Panel: (ALB, ALP, ALT, AST, BUN, Ca, Chol, CK, Creat,

Gluc, Tbili, TProt, Trig, Electroytes) ** 270 uL

McMasters Pig Full Chemistry Panel: (ALB, ALP, AST, BUN, Ca, Chol, CK, Creat, Gluc, TBili, TProt, Trig, Electrolytes)

Verify Biological Indicators Location (check one): All individual chemistries offered: ALB, ALP, ALT, AST, BUN, Ca, CHOLI, CK, CREA, GLUC, LDH, TBIL, Mg, PHOS, TPRO, TRIG, ISE Na, K, CI MSRB Cagewash MSRB Nude BSRB Clean

BSRB Dirty Cancer Center Brehm Bulk Use this space to prioritize chemistries if you are low on volume: LSI Cleanside LSI Bulk NCRC #1 #2 #3 #4 #5

Other: #6 #7 #8 #9 #10 Autoclave Cycle (check one):

Electrolytes requires 150uL of serum, giving them low priority will save volume for other tests. * We strongly encourage you to consult our lab in regards to minimum volume required. Please refer to the IVAC website for more information. ** Minimum serum volume does not allow for reruns or fibrin clots in the sample, higher volume is recommended if possible.

Gravity Liquid

Other: Cycle 1 Cycle 2

Cycle 3 Cycle 4

Results (IVAC Use Only): Liquid Other:Other:

Negative Positive Inconclusive

Rev. 09/19/2018

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Chemistries:Individual or Profile Panels. Preferred in serum separator yellow top tubes.

Red top tubes tend to yield hemolyzed serum.