Arthropod Specimen Identification Form - Illinois

This Illinois-specific "Arthropod Specimen Identification Form" is a document released by the Illinois Department of Public Health.

Download the fillable PDF by clicking the link below and use it according to the applicable legal guidelines.

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Arthropod Specimen Identification
SPECIMEN IDENTIFICATION, Illinois Dept. of Public Health,
SEND TO>
Div. of Environmental Health, 525 W. Jefferson St., Springfield, IL 62761
SUBMITTED BY___________________________________________ DATE___________________
PERSON TO RECEIVE IDENTIFICATION INFORMATION (if different from above)
:)
NAME___________________________________________________ PHONE__________________
ORGANIZATION____________________________________________________________________
ADDRESS
(information will be sent
here)_________________________________________________
_________________________________________________________ ZIP CODE________________
COLLECTION INFORMATION COLLECTED FROM: CITY__________________CO._____________
CIRCUMSTANCES__________________________________________________________________
(e.g., found in garden, in food, in pet bedding, on person, in stool sample, etc.)
ADDITIONAL INFORMATION
:
(Do not use patient names)
Specimen ID Number: (assigned by submitting organization) _________________________________
Clinic/Hospital_____________________________________ Department_______________________
Address___________________________________________________________Zip Code________
Attending Physician________________________ OR Contact Person_________________________
PLEASE NOTE
:
1
Submit specimens in leak-proof containers. Avoid taping or gluing specimens.
2
Certain specimens (e.g., ticks, insect larvae) should be in 70% ethanol or isopropyl alcohol.
3
Mail specimens in crush-proof containers (plastic vials, med/specimen bottles, boxes, etc.).
4
Specimens will be identified, but not tested for the presence of pathogens or disease.
5
Most specimens are identified and a written report mailed the same day they are received.
Curt Colwell, PhD
If you do not receive information within 7 days, please contact
at
217-782-5830 or e-mail CURT.COLWELL@ILLINOIS.GOV
6
This form is online at: www.idph.state.il.us/forms/ohp/ArthropodSpecimenForm.pdf
DETERMINATION : (for IDPH use) ______________________________________________________
IDPH specimen #_____________ Date Identified ______________ Identified by__________________
Arthropod Specimen Identification
SPECIMEN IDENTIFICATION, Illinois Dept. of Public Health,
SEND TO>
Div. of Environmental Health, 525 W. Jefferson St., Springfield, IL 62761
SUBMITTED BY___________________________________________ DATE___________________
PERSON TO RECEIVE IDENTIFICATION INFORMATION (if different from above)
:)
NAME___________________________________________________ PHONE__________________
ORGANIZATION____________________________________________________________________
ADDRESS
(information will be sent
here)_________________________________________________
_________________________________________________________ ZIP CODE________________
COLLECTION INFORMATION COLLECTED FROM: CITY__________________CO._____________
CIRCUMSTANCES__________________________________________________________________
(e.g., found in garden, in food, in pet bedding, on person, in stool sample, etc.)
ADDITIONAL INFORMATION
:
(Do not use patient names)
Specimen ID Number: (assigned by submitting organization) _________________________________
Clinic/Hospital_____________________________________ Department_______________________
Address___________________________________________________________Zip Code________
Attending Physician________________________ OR Contact Person_________________________
PLEASE NOTE
:
1
Submit specimens in leak-proof containers. Avoid taping or gluing specimens.
2
Certain specimens (e.g., ticks, insect larvae) should be in 70% ethanol or isopropyl alcohol.
3
Mail specimens in crush-proof containers (plastic vials, med/specimen bottles, boxes, etc.).
4
Specimens will be identified, but not tested for the presence of pathogens or disease.
5
Most specimens are identified and a written report mailed the same day they are received.
Curt Colwell, PhD
If you do not receive information within 7 days, please contact
at
217-782-5830 or e-mail CURT.COLWELL@ILLINOIS.GOV
6
This form is online at: www.idph.state.il.us/forms/ohp/ArthropodSpecimenForm.pdf
DETERMINATION : (for IDPH use) ______________________________________________________
IDPH specimen #_____________ Date Identified ______________ Identified by__________________

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