Form FDACS-09212 "Accession General Submission Form" - Florida

Form FDACS-09212 is a Florida Department of Agriculture and Consumer Services form also known as the "Accession General Submission Form". The latest edition of the form was released in February 1, 2018 and is available for digital filing.

Download a PDF version of the Form FDACS-09212 down below or find it on Florida Department of Agriculture and Consumer Services Forms website.

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Download Form FDACS-09212 "Accession General Submission Form" - Florida

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Florida Department of Agriculture and Consumer Services
Contact Information:
Division of Animal Industry
Bronson Animal Disease
Bureau of Diagnostic Laboratory
Diagnostic Laboratory
Phone: (321) 697-1400
Fax: (321) 697-1467
ACCESSION GENERAL SUBMISSION FORM
ADAM H. PUTNAM
COMMISSIONER
FreshFromFlorida.com/BADDL
Chapter 585, Florida Statutes
Note: All documents and attachments submitted with this request are subject to public review pursuant to Chapter 119, F.S.
Sample Information
Send Results by:
Accession Number
Mail
Fax
Collection Date
$2 Mail/Fax
E-Mail
Report Fee
(no fee)
Premise ID
Each Report
FDACS Use Only
Submitter
Owner
-
Same as Submitter
Name
Name
Clinic
Address
Name
City,
Address
State, Zip
City, State, Zip
Phone
Phone
Mobile
Animal Identification (Use Continuation Form FDACS-09228 for additional specimens / history)
Sex Codes: M=Male, F=Female, C=Castrated Male, S=Spayed Female
Animal or Sample ID
Species
Breed
Sex
Age
Tests Requested*
1
2
3
4
5
6
7
8
*For up-to-date test list, sample requirements and pricing information, please visit our website at:
FreshFromFlorida.com/BADDL
Sample Description:
Blood, EDTA
Qty:
Serum
Qty:
Feces
Qty:
Hair
Qty:
Type and Quantity of
Tissue (fixed)
Qty:
Fluid
Qty:
Slide
Qty:
Swab
Qty:
Specimens:
Tissue (fresh)
Qty:
Carcass
Qty:
Other
Qty:
Testing Purpose:
Clinical
Regulatory
Surveillance
Import
Export Country of Destination:
Type of flock/herd:
Size of flock/herd:
Number sick:
Number sampled:
History / Provisional Diagnosis:
If necropsy,
Natural Death
Euthanasia
Date & time of death:
Bronson Animal Disease Diagnostic Laboratory Delivery Service Address
2700 N John Young Pkwy, Kissimmee, FL 34741-1266
* We regret that we are unable to return any animal samples or remains submitted for necropsy or other analyses.
FDACS-09212 Rev. 02/18
Florida Department of Agriculture and Consumer Services
Contact Information:
Division of Animal Industry
Bronson Animal Disease
Bureau of Diagnostic Laboratory
Diagnostic Laboratory
Phone: (321) 697-1400
Fax: (321) 697-1467
ACCESSION GENERAL SUBMISSION FORM
ADAM H. PUTNAM
COMMISSIONER
FreshFromFlorida.com/BADDL
Chapter 585, Florida Statutes
Note: All documents and attachments submitted with this request are subject to public review pursuant to Chapter 119, F.S.
Sample Information
Send Results by:
Accession Number
Mail
Fax
Collection Date
$2 Mail/Fax
E-Mail
Report Fee
(no fee)
Premise ID
Each Report
FDACS Use Only
Submitter
Owner
-
Same as Submitter
Name
Name
Clinic
Address
Name
City,
Address
State, Zip
City, State, Zip
Phone
Phone
Mobile
Animal Identification (Use Continuation Form FDACS-09228 for additional specimens / history)
Sex Codes: M=Male, F=Female, C=Castrated Male, S=Spayed Female
Animal or Sample ID
Species
Breed
Sex
Age
Tests Requested*
1
2
3
4
5
6
7
8
*For up-to-date test list, sample requirements and pricing information, please visit our website at:
FreshFromFlorida.com/BADDL
Sample Description:
Blood, EDTA
Qty:
Serum
Qty:
Feces
Qty:
Hair
Qty:
Type and Quantity of
Tissue (fixed)
Qty:
Fluid
Qty:
Slide
Qty:
Swab
Qty:
Specimens:
Tissue (fresh)
Qty:
Carcass
Qty:
Other
Qty:
Testing Purpose:
Clinical
Regulatory
Surveillance
Import
Export Country of Destination:
Type of flock/herd:
Size of flock/herd:
Number sick:
Number sampled:
History / Provisional Diagnosis:
If necropsy,
Natural Death
Euthanasia
Date & time of death:
Bronson Animal Disease Diagnostic Laboratory Delivery Service Address
2700 N John Young Pkwy, Kissimmee, FL 34741-1266
* We regret that we are unable to return any animal samples or remains submitted for necropsy or other analyses.
FDACS-09212 Rev. 02/18
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