general submission / necropsy form · general submission / necropsy form ... serology parasitology...

GENERAL SUBMISSION / NECROPSY FORM VBSD.ADRDL.FORM.SPR.0001.04 Last Revised 01.08.16

South Dakota State University

Animal Disease Research & Diagnostic Lab

1155 North Campus Drive

Accession Number

Date

Brookings, SD 57007

605.688.5171 605.688.6003 (fax) email: sdsu.adrdl@sdstate.edu

website: http://sdstate.edu/vs

SPECIES

Breed

Age

# in Herd

# Dead

# Sick

DVM

Clinic

Sex Address

Animal ID Number(s) City

CHECK ANY THAT APPLY: Zip State

Lameness Diarrhea

Abortion

Pneumonia

Phone Fax CNS Other

Vaccinations

Treatments

Copy to

Export to OWNER

Premise ID

City

NO YES IS THIS A RABIES SUSPECT? Pet Stray Wildlife

State WAS THIS ANIMAL VACCINATED FOR RABIES? When? NO YES

DID THIS ANIMAL EXPOSE ANY OTHER ANIMALS

TO RABIES? State Zip Type? NO YES

HUMAN EXPOSURE?

Person(s)

Fax Phone

Address

City HISTORY (include signs

of suspect

rabid animal

if appropriate)

State

IF RABIES IS NEGATIVE DO YOU

WANT A COMPLETE NECROPSY? NO YES

Tentative

Diagnosis

IF SWINE SIV SUBMISSION: Gross

Necropsy

Lesions H1N1 Public Health Investigation

Sick Pigs

Commingled Pigs

Body Serum Whole Blood Feces # OF SPECIMENS Date Collected

Fluid/Swab Tissue (list)

I request a complete diagnostic examination (at discretion of Laboratory)

I request ONLY the following services/tests: Bacteriology Histopath Virology Immunohistochemistry Molecular Diagnostics (PCR)

Serology Parasitology Rabies Test Tox Exam (list specific toxin)

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.

This box

is for

client's

internal use

only.