Form CF.ACC.1.9 "General Submission Form" - Alabama

What Is Form CF.ACC.1.9?

This is a legal form that was released by the Alabama Department of Agriculture and Industries - a government authority operating within Alabama. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2019;
  • The latest edition provided by the Alabama Department of Agriculture and Industries;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CF.ACC.1.9 by clicking the link below or browse more documents and templates provided by the Alabama Department of Agriculture and Industries.

ADVERTISEMENT
ADVERTISEMENT

Download Form CF.ACC.1.9 "General Submission Form" - Alabama

474 times
Rate (4.3 / 5) 28 votes
AVDL
Alabama Veterinary
ACCESSION #:
Diagnostic Laboratory System
Regional Lab
Auburn Lab
DATE
www.labs.alabama.gov
RECEIVED:
 J. B. Taylor
CASE
 Thompson Bishop Sparks
 Mitchem-Sparks
 Hinton Mitchem
State Diagnostic Lab.
Diagnostic Lab.
Poultry Diagnostic Lab.
Diagnostic Lab. 495
COORDINATOR:
890 Simms Rd.
1833 Industrial Blvd
1001 College Dr.
State Road 203
CHARGE
N/C PAID: $
CASH
CHECK #
Elba, AL 36323 Ph:
Auburn, AL 36832
Boaz, AL 35957
Hanceville, AL 35077
Regional Lab
Auburn Lab
(334) 897-6340
Ph: (334) 844-4987
Ph: (256) 593-2995
Ph: (256) 352-8036
Tech Initials
Tech Initials
Fax: 334-897-0272
Fax: (334) 844-7206
Fax: (256) 593-2996
Fax: (256) 352-8038
General Submission Form
USPS UPS FEDEX OTHER:
Submitted by:
Veterinarian
Owner
Other:
Please check
www.labs.alabama.gov
for submission recommendations and our current fee schedule.
Some tests may be subcontracted/referred to qualified laboratories. Submitter will be contacted for permission if this will incur additional charges.
All submitted samples and sample data become property of ADAI. Remains of animals cannot be returned to clients, but cremation can be arranged by the client if desired.
Veterinarian
Owner
Clinic
Business
Premise ID
License#
Account#
County
Address
Address
City
State
Zip
City
State
Zip
Phone
Phone
Fax
Fax
Email
Email
Previous Case # (if applicable)
Report to:
Bill to:
Vet
Own
Other:
Vet
Own
Other:
email
fax
mail
email
fax
mail
Report preference:
Bill preference:
For multiple animals use the multiple animal continuation form.
Animal ID numbers for deer or deer heads submitted will be shared with ADCNR.
Specimen:
Whole body
Fresh Tissue
Fixed Tissue
Blood
Serum
Urine
Feed/Hay
Other
Animal ID or name
Species
Breed
(Lab. Use Only)
Test Sections
Necropsy
________________
Sex
Age
Practitioner
________________
Years
Months
Days
Necropsy
________________
History
:
Regional Lab Tests
(diet, vaccine, nutrition, illnesses, herd, etc.)
Disposal Only
________________
Necropsy
Histopathology
________________
Practitioner
Bacteriology
________________
Necropsy
Mycology
________________
Clinical signs/symptoms:
Bacteriology
Virology
________________
Mycology
Molecular/PCR
________________
Serology
Serology
________________
Recent changes
:
(diet, herd, travel, etc)
Toxicology
________________
Rabies, ADPH
Parasitology
________________
USDA
Rabies, ADPH
________________
BSE
AUCVM
________________
Treatment/Medications:
Scrapie
CWD
________________
HOLD
BSE
________________
Parasitology
Diagnosis/differentials:
Scrapie
________________
Other:
HOLD
________________
Other:
______________
#Herd
#Sick
#Dead:
Attach additional sheets if needed.
IF NECROPSY: Date of death:
Died
Euthanized Method of euthanasia:
Barbiturate
Other (specify)
IF RABIES SUSPECT:
Rabies testing only
Rabies testing plus necropsy
Legal (+$75 fee)
Insured (+$75 fee)
DISPOSAL:
Routine disposal (included)
Cremation (arranged & paid for by client) Cremation service:
Print Name
Signature
Date
AVDL Submission Form CF.ACC.1.9
NOV 2019
KS
1 of 2
AVDL
Alabama Veterinary
ACCESSION #:
Diagnostic Laboratory System
Regional Lab
Auburn Lab
DATE
www.labs.alabama.gov
RECEIVED:
 J. B. Taylor
CASE
 Thompson Bishop Sparks
 Mitchem-Sparks
 Hinton Mitchem
State Diagnostic Lab.
Diagnostic Lab.
Poultry Diagnostic Lab.
Diagnostic Lab. 495
COORDINATOR:
890 Simms Rd.
1833 Industrial Blvd
1001 College Dr.
State Road 203
CHARGE
N/C PAID: $
CASH
CHECK #
Elba, AL 36323 Ph:
Auburn, AL 36832
Boaz, AL 35957
Hanceville, AL 35077
Regional Lab
Auburn Lab
(334) 897-6340
Ph: (334) 844-4987
Ph: (256) 593-2995
Ph: (256) 352-8036
Tech Initials
Tech Initials
Fax: 334-897-0272
Fax: (334) 844-7206
Fax: (256) 593-2996
Fax: (256) 352-8038
General Submission Form
USPS UPS FEDEX OTHER:
Submitted by:
Veterinarian
Owner
Other:
Please check
www.labs.alabama.gov
for submission recommendations and our current fee schedule.
Some tests may be subcontracted/referred to qualified laboratories. Submitter will be contacted for permission if this will incur additional charges.
All submitted samples and sample data become property of ADAI. Remains of animals cannot be returned to clients, but cremation can be arranged by the client if desired.
Veterinarian
Owner
Clinic
Business
Premise ID
License#
Account#
County
Address
Address
City
State
Zip
City
State
Zip
Phone
Phone
Fax
Fax
Email
Email
Previous Case # (if applicable)
Report to:
Bill to:
Vet
Own
Other:
Vet
Own
Other:
email
fax
mail
email
fax
mail
Report preference:
Bill preference:
For multiple animals use the multiple animal continuation form.
Animal ID numbers for deer or deer heads submitted will be shared with ADCNR.
Specimen:
Whole body
Fresh Tissue
Fixed Tissue
Blood
Serum
Urine
Feed/Hay
Other
Animal ID or name
Species
Breed
(Lab. Use Only)
Test Sections
Necropsy
________________
Sex
Age
Practitioner
________________
Years
Months
Days
Necropsy
________________
History
:
Regional Lab Tests
(diet, vaccine, nutrition, illnesses, herd, etc.)
Disposal Only
________________
Necropsy
Histopathology
________________
Practitioner
Bacteriology
________________
Necropsy
Mycology
________________
Clinical signs/symptoms:
Bacteriology
Virology
________________
Mycology
Molecular/PCR
________________
Serology
Serology
________________
Recent changes
:
(diet, herd, travel, etc)
Toxicology
________________
Rabies, ADPH
Parasitology
________________
USDA
Rabies, ADPH
________________
BSE
AUCVM
________________
Treatment/Medications:
Scrapie
CWD
________________
HOLD
BSE
________________
Parasitology
Diagnosis/differentials:
Scrapie
________________
Other:
HOLD
________________
Other:
______________
#Herd
#Sick
#Dead:
Attach additional sheets if needed.
IF NECROPSY: Date of death:
Died
Euthanized Method of euthanasia:
Barbiturate
Other (specify)
IF RABIES SUSPECT:
Rabies testing only
Rabies testing plus necropsy
Legal (+$75 fee)
Insured (+$75 fee)
DISPOSAL:
Routine disposal (included)
Cremation (arranged & paid for by client) Cremation service:
Print Name
Signature
Date
AVDL Submission Form CF.ACC.1.9
NOV 2019
KS
1 of 2
Mammal Specimens & Tests
Accession #
Bacteriology/Mycology
Virology
Specimen
Tests
Specimen
Feline
Bovine
Lung
Aerobic culture/sensitivity
Lung
Calicivirus FA
Coronavirus FA
Liver
Anaerobic culture
Liver
Coronavirus (FCoV) FA
Parainfluenza 3 FA
Kidney
Fungal culture
Kidney
Herpes (FVR-1) FA
BVD Ear Notch ELISA
Spleen
Brucella culture
Spleen
Panleukopenia virus FA
Sm. Intestine
Salmonella culture
Brain
Ovine/ Caprine
Lg. Intestine/Cecum
Campylobacter culture
Small intestine
Canine
Contagious ecthyma
Brain
Johne’s culture
Lymph node
Coronavirus FA
FA
Muscle
Listeria culture
Ear notch
Distemper virus FA
Lymph Node
Listeria cold enrichment culture
Retropharyngeal
Adenovirus FA
Multiple species
Urine
(brain only)
lymph nodes
Herpesvirus FA
Rotavirus ELISA
Feces
Other:
_
fresh & fixed*
Parvovirus FA
Other:
_
Swab
Stains
1/2 obex fresh &
Cervid
Instructions:
Abscess/Lesion
Cryptosporidium: Auramine-O
1/2 obex fixed*
_
_
acid fast stain
Ear tag w/skin*
CWD ELISA*
Cytology/impression
Blackleg: Fluorescent antibody
Feces
slide
Other:
_
Swab:
_
Instructions:
Other:
_
_
Other:
_
*CWD sampling procedures
must be followed. Please
call with questions.
Toxicology
Molecular/PCR
Specimen**
Tests
Specimen
Bovine
Porcine
Liver
Cyanide
Potassium
Lung
Bovine respiratory
PEDV
Kidney
Ethylene glycol
Selenium
Liver
BRSV
Stomach contents
Insecticide
Salt
Kidney
BVDV
Cervid
Serum
screen
Zinc
Spleen
IBR
Bluetongue virus
Blood
Rodenticide
Nitrate & Nitrite
Brain
Mycoplasma
EHDV
Vitreous Humor
screen
pH
Intestine
Bluetongue
Aqueous Humor
Strychnine
Mycotoxins:
Lymph node
Chlamydia
Canine
Feed
Arsenic
Aflatoxin
Swab:
Tritrichomonas
Herpesvirus
Hay
Cadmium
Deoxynivalenol
______
Equine
Multiple species
Other:
_
Calcium
Fumonisin B1
Brain, Heart,
Phosphorus
Ochratoxin
Spleen
EEE
Mycoplasma
(sent to NVSL)
Instructions:
Chromium
Ionophores
Other:
___
EHV-1
WNV
(respiratory)
Copper
Feed visual exam
WNV
Chlamydia
Instructions:
Iron
Bone ash
EVA
Clostridium perfringens
Lead
Urolith analysis
Influenza
Magnesium
Other:
_
**Please submit liver,
kidney, and stomach
or rumen contents on
all necropsies when
Toxicology is
requested.
Serology
Histopathology (Necropsy)
Porcine
Bovine
Equine
Brain
Stomach
Ovary
Brucella suis
Bovine abortion panel
EIA/Coggins
Lung
Rumen
Testicle
Pseudorabies
Anaplasmosis
Liver
Intestine
Mammary
(separate form)
Bluetongue virus
EVA
Kidney
Cecum
Placenta
Ovine/Caprine
Brucellosis (B. abortus)
EEE
Heart
Colon
Trachea
CAE
BVDV
EHV-1
Spleen
Tonsil
U. bladder
(respiratory)
Ovine progressive
IBR
WNV
Lymph Node
Adrenal
Bone marrow
pleuropneumonia
Neosporosis
Thymus
Thyroid
Other:
Johne’s disease
Leptospirosis panel
Multiple Species
Muscle
Uterus
Other:
_
Bovine respiratory panel
Leptospirosis panel
(caprine)
BVDV
Bluetongue
Canine
IBR
Brucella abortus/suis
Brucella canis
PI-3
Instructions:
Leptospirosis panel
BRSV
_
Parasitology
Bovine leukosis virus
Fecal flotation
(centrifugation)
Feline
Johne’s disease
Direct smear
FELV
IgG
(passive transfer)
Zinc Sulfate Flotation
FIV
McMasters Egg Count
Coronavirus (FCoV)
Kaplan Lab McMasters
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.
AVDL Submission Form CF.ACC.1.8
AUG 2019
KS
2 of 2
Page of 2