"General Submission Form" - Alabama

General Submission Form is a legal document that was released by the Alabama Department of Agriculture and Industries - a government authority operating within Alabama.

Form Details:

  • Released on January 1, 2016;
  • The latest edition currently provided by the Alabama Department of Agriculture and Industries;
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  • Fill out the form in our online filing application.

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AVDL
Alabama Veterinary
ACCESSION #:
Diagnostic Laboratory System
Regional Lab.
Auburn Lab.
DATE
www.labs.alabama.gov
RECEIVED:
 Thompson Bishop Sparks
 Mitchem-Sparks
 Hinton Mitchem
 J. B. Taylor
CASE
State Diagnostic Lab.
Diagnostic Lab.
Poultry Diagnostic Lab.
Diagnostic Lab.
COORDINATOR:
890 Simms Rd.
1833 Industrial Blvd
1001 College Dr.
495 State Road 203
CHARGE
N/C PAID: $
CASH
CHECK #
Auburn, AL 36832
Boaz, AL 35957
Hanceville, AL 35077
Elba, AL 36323
Regional Lab.
Auburn Lab.
Ph: (334) 844-4987
Ph: (256) 593-2995
Ph: (256) 352-8036
Ph: (334) 897-6340
Tech Initials
Tech Initials
Fx: (334) 844-7206
Fx: (256) 593-2996
Fx: (256) 352-8038
Fx: (334) 897-8813
USPS UPS FEDEX OTHER:
General Submission Form
Submitted by:
Veterinarian
Owner
Other:
*ALL submitted samples become the property of AVDL*
*Some tests may be sub-contracted to qualified laboratories. Submitter will be contacted for permission if this will incur additional charges*
Veterinarian
Owner
Clinic
Business
License#
Account#
County
Address
Address
City
State
Zip
City
State
Zip
Phone
Phone
Fax
Fax
Email
Email
Previous Case #
Report to:
Vet
Own
Other:
Bill to:
Vet
Own
Other:
email
fax
mail
email
fax
mail
Report preference:
Bill preference:
*For multiple animals use the multiple animal continuation form
*For surgical pathology see back
Specimen:
Whole body
Fresh Tissue
Fixed Tissue
Blood
Serum
Feed/Hay
Other
Animal ID
Species
Breed
(Lab. Use Only)
Test Sections
Necropsy
________________
Sex
Age
Practitioner Nec.
________________
Years
Months
Days
Disposal Only
________________
History / Clinical Signs:
Regional Lab Tests
Histopathology
________________
Necropsy
Cytology
________________
Practitioner Nec.
Bacteriology
________________
Bacteriology
Mycology
________________
Mycology
Virology
________________
Serology
Molecular/PCR
________________
Serology
________________
Rabies, ADPH
Toxicology
________________
USDA
Parasitology
________________
BSE
Rabies, ADPH
________________
Scrapie
AUCVM
________________
HOLD
CWD
________________
Other:
BSE
________________
Parasitology:
Scrapie
________________
HOLD
________________
Other:
________________
Treatment:
Diagnosis/Differential:
Euthanized
Died
Date
Legal
Insured
Rabies Suspect
Herd status (if applicable):
# Herd:
# Sick:
# Dead:
Print Name
Signature
Date
CF.ACC.1.7 AVDL General Submission Form
1 of 2
JAN 2016
TSG/AG
AVDL
Alabama Veterinary
ACCESSION #:
Diagnostic Laboratory System
Regional Lab.
Auburn Lab.
DATE
www.labs.alabama.gov
RECEIVED:
 Thompson Bishop Sparks
 Mitchem-Sparks
 Hinton Mitchem
 J. B. Taylor
CASE
State Diagnostic Lab.
Diagnostic Lab.
Poultry Diagnostic Lab.
Diagnostic Lab.
COORDINATOR:
890 Simms Rd.
1833 Industrial Blvd
1001 College Dr.
495 State Road 203
CHARGE
N/C PAID: $
CASH
CHECK #
Auburn, AL 36832
Boaz, AL 35957
Hanceville, AL 35077
Elba, AL 36323
Regional Lab.
Auburn Lab.
Ph: (334) 844-4987
Ph: (256) 593-2995
Ph: (256) 352-8036
Ph: (334) 897-6340
Tech Initials
Tech Initials
Fx: (334) 844-7206
Fx: (256) 593-2996
Fx: (256) 352-8038
Fx: (334) 897-8813
USPS UPS FEDEX OTHER:
General Submission Form
Submitted by:
Veterinarian
Owner
Other:
*ALL submitted samples become the property of AVDL*
*Some tests may be sub-contracted to qualified laboratories. Submitter will be contacted for permission if this will incur additional charges*
Veterinarian
Owner
Clinic
Business
License#
Account#
County
Address
Address
City
State
Zip
City
State
Zip
Phone
Phone
Fax
Fax
Email
Email
Previous Case #
Report to:
Vet
Own
Other:
Bill to:
Vet
Own
Other:
email
fax
mail
email
fax
mail
Report preference:
Bill preference:
*For multiple animals use the multiple animal continuation form
*For surgical pathology see back
Specimen:
Whole body
Fresh Tissue
Fixed Tissue
Blood
Serum
Feed/Hay
Other
Animal ID
Species
Breed
(Lab. Use Only)
Test Sections
Necropsy
________________
Sex
Age
Practitioner Nec.
________________
Years
Months
Days
Disposal Only
________________
History / Clinical Signs:
Regional Lab Tests
Histopathology
________________
Necropsy
Cytology
________________
Practitioner Nec.
Bacteriology
________________
Bacteriology
Mycology
________________
Mycology
Virology
________________
Serology
Molecular/PCR
________________
Serology
________________
Rabies, ADPH
Toxicology
________________
USDA
Parasitology
________________
BSE
Rabies, ADPH
________________
Scrapie
AUCVM
________________
HOLD
CWD
________________
Other:
BSE
________________
Parasitology:
Scrapie
________________
HOLD
________________
Other:
________________
Treatment:
Diagnosis/Differential:
Euthanized
Died
Date
Legal
Insured
Rabies Suspect
Herd status (if applicable):
# Herd:
# Sick:
# Dead:
Print Name
Signature
Date
CF.ACC.1.7 AVDL General Submission Form
1 of 2
JAN 2016
TSG/AG
*Indicate all submitted samples and the appropriate test section(s). If no tests are selected, tests will be performed at the discretion of the pathologist*
*The appropriate sample must be submitted for the test to be performed*
Specimens & Tests
Accession #
Bacteriology/Mycology
Virology
Specimen
Mammal / Avian Tests
Specimen
Mammal Tests
Avian Tests
Lung
Aerobic culture/sensitivity
Lung
Feline
Adenovirus
Liver
Anaerobic culture
Liver
Calicivirus FA
Enteric Virus profile
Kidney
Fungal culture
Kidney
FIP FA
Astrovirus
Spleen
Salmonella culture
Spleen
Panleukopenia virus FA
Rotavirus
Brain
Other:
Brain
Viral rhinotracheitis FA
Reovirus (VA, Enteric)
Skin
Mammal Tests
Lesion
Canine
Reticuloendotheliosis virus
Lymph Node
Campylobacter culture
Lymph Node
Coronavirus FA
Pox
Conjunctiva
Johne’s culture
Trachea
Distemper virus FA
Respiratory Virus Profile
Urine
Listeria
Cecal Tonsil
Adenovirus FA
(IBV, NDV, LTV, AIV)
Avian Tests
Feces
Thymus
Herpesvirus FA
Other:
Sm. Intestine
Botulinum toxin bioassay (Type C)
Conjunctiva
Parvovirus FA
Instructions:
Lg. Intestine/Cecum
Stains
Tendon
Bovine
Joint/Bone Marrow
Gram stain
Feces
Coronavirus FA
Swab
Acid fast stain
Sm. Intestine
Parainfluenza 3 FA
Auramine-O acid fast
Swab:
BVD Ear Notch ELISA
Abscess/Lesion
Ovine/ Caprine
(Cryptosporidium)
Choana
Fluorescent antibody (Blackleg)
Eye
Contagious ecthyma FA
Cloaca
Other:
Nasal
Mammal Miscellaneous
Air sac
Instructions:
Other:
Rotavirus ELISA
Joint
Other:
Cytology/impression slide
Other:
Toxicology
Molecular/PCR
Specimen
Tests
Specimen
Mammal Tests
Avian Tests
Liver
Cyanide
Vitamin E
Lung
Bovine
Mycoplasma gallisepticum (MG)
Kidney
Ethylene Glycol
Sodium/Salt
Liver
Bluetongue virus
Mycoplasma synoviae (MS)
Stomach Contents
Insecticide screen
Zinc
Spleen
BRSV
Avibacterium paragallinarum
Crop/Gizzard Cts.
Rodenticide screen
Nitrate & Nitrite
Thymus
BVDV
Respiratory Virus Profile
Serum
Arsenic
pH
Brain
Chlamydophila
LT
Blood
Cadmium
Mycotoxin-
Intestine
IBR
IBV
Hair
Calcium
Aflatoxin
Swab:
Mycoplasma
AI
Fat
Phosphorus
Ionophores
Tritrichomonas PCR
NDV
Vitreous Humor
Chromium
Nutrient Panel:
Cloaca (BHI)
Cervid
Enteric Virus profile
Aqueous Humor
Copper
fat, fiber, protein,
Pharyngeal(BHI)
Bluetongue virus
Astrovirus
Feed
Iron
Urea(NPN)
Trachea
EHDV
Rotavirus
Hay
Lead
Feed visual exam
Brain,Heart,Spleen
Equine
Parvovirus
Other:
Magnesium
Bone ash
Other:
EEE
Reovirus
Instructions:
Potassium
Urolith analysis
Instructions:
EHV-1
Chicken Infectious Anemia
Selenium
Other:
EVA
Avian Leukosis virus subgroup J
Vitamin A
Other:
WNV
Adenovirus
Miscellaneous
Polyomavirus
AUCVM/Parasitology
Mycoplasma
WNV
Fecal flotation
McMasters Egg Count
WNV
EEE
Protozoa, coccidia
Parasite identification
Zinc Sulfate Flotation (Giardia)
Other:
Avian Serology
Mammal Serology
Pathology (Necropsy/Practitioner Necropsy)
terial Serology
Bovine
Equine
Brain
Rumen
Bursa
Mycoplasma gallisepticum
Abortion panel
EIA/Coggins (separate form)
Lung
Intestine
Proventriculus
Mycoplasma synoviae
Anaplasmosis
EEE ELISA
Liver
Cecum
Gizzard
Mycoplasma HI test
Bluetongue virus
EHV-1 SN
Kidney
Colon
Eyelid
Salmonella pullorum
Bovine brucellosis
EVA SN
Heart
Placenta
Thymus
Salmonella other
Bovine leukosis virus
WNV ELISA
Spleen
Uterus
Other:
Other:
BRSV SN
Canine
Lymph Node
Trachea
Other:
BVDV SN
Brucella canis
Stomach
Viral Serology
IBR SN
Blastomycosis
Surgical Pathology
Avian Encephalomyelitis
PI3 SN
Histoplasmosis
Mass
Multiple Masses
Lesion:
Avian Influenza
Johne’s disease
Feline
Chicken Infectious Anemia
Neosporosis
FELV
Duration:
Infectious Bronchitis
Ovine/Caprine
FIV
Infectious Bursal Disease
CAE
FIP (Coronavirus)
Distribution:
Newcastle (paramyxovirus
Ovine brucellosis
Multiple Species / Misc.
type 1)
Ovine progressive
Leptospirosis Panel
Reovirus
pleuropneumonia
IgG (Passive transfer)
Treatment:
Pneumovirus (referred to NVSL)
Porcine
EHD
Response:
Other:
Brucellosis
Other:
Instructions:
Pseudorabies
Instructions:
Diagnosis/Differential:
CF.ACC.1.7 AVDL General Submission Form
2 of 2
JAN 2016
TSG/AG
Page of 2