general submission / necropsy form · general submission / necropsy form ... serology parasitology...
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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: [email protected]
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.