Form LSAD101F3.5 "Avian Submission Form" - Nova Scotia, Canada

ADVERTISEMENT
ADVERTISEMENT

Download Form LSAD101F3.5 "Avian Submission Form" - Nova Scotia, Canada

284 times
Rate (4.4 / 5) 20 votes
AHL LABORATORY ID:
Avian Submission Form
Animal Health Laboratory
DATE RECEIVED:
NS Department of Agriculture
Physical Address:
Date Sampled:
Hancock Building 65 River Rd.
Bible Hill, NS B2N 2P3
Date Submitted:
PH. (902) 893-6540 / Fax (902) 895-6684
Sample Submitted by:
Owner
Veterinarian
Mailing Address:
P.O. Box 890, Truro, NS
B2N 5G6
Send Report to:
Owner
Veterinarian
Other
Specify:
How you would like to receive your report (check one)
Email
Fax
Mail
Veterinarian:
Owner Information
Name:
Veterinary Clinic
Farm Name:
Email/Fax:
Address:
Number of Specimens
Sample ID
No. Sent
Specimen Type
No. Received
□_________
_______
Carcass
_______
□_________
_______
Whole Blood
_______
Postal Code:
□_________
_______
Serum
_______
Phone:
Fax:
_______
Urine
_______
□_________
_______
Feces
_______
□_________
Email:
_______
Fresh Tissue
_______
□_________
_______
Fixed Tissue
_______
□_________
_______
Fluid
_______
Premise ID:
_______
Swab
_______
□_________
_______
Peptones
_______
□_________
Farm ID: ______________
Breed: _______________
_______
Fluffs
_______
□_________
_______
Other: ____________ _______
Flock ID:______________
Age: ______□d □w □m □y
□_________
_______
Other: ____________ _______
Flock Code: ___________
Sex: □ M □ F □ Mixed
□_________
_______
Other: ____________ _______
Turkey:
Chicken:
History and Special Requests (additional space on back)
□ Meat
□ Broiler
(presenting illness, clinical signs, treatments, vaccinations, etc)
□ Breeder
□ Broiler-Breeder
□ Small Flock
□ Layer
□ Exhibition
□ Layer-Breeder
□ Small Flock
Farm Population:
□ Exhibition
No. at Risk ____________
□ Hatchery
No. sick
____________
No. Dead ____________
Duration of problem:
_______ □d □w □m □y
Serology
Bacteriology
Parasitology
Pathology
□ MG/MS ELISA
□ AEV-ELISA
□ Aerobic Culture
□ Fecal flotation
□Necropsy
□ CAV-ELISA
□ IBDV-XR-ELISA
□ Histopathology
Aerobic Culture & Sensitivity
□ IBV-ELISA
□ NDV-ELISA
Virology
Other
Salmonella BAX (Fluff)
□ Reovirus-ELISA
□___________
□___________
Salmonella BAX (Peptone)
□ FAdV microneutralization
□___________
□___________
Salmonella BAX (Other)
□______________________
□___________
□___________________
□______________________
LSAD101F3.5
Page 1 of 2
Results derived from testing may be used for statistical surveillance of animal health in Nova Scotia. Laboratory Services complies with the
Federal Health of Animals Act. Laboratory Services will make all reasonable efforts to keep personal information confidential and not disclose
personal identifiers.
AHL LABORATORY ID:
Avian Submission Form
Animal Health Laboratory
DATE RECEIVED:
NS Department of Agriculture
Physical Address:
Date Sampled:
Hancock Building 65 River Rd.
Bible Hill, NS B2N 2P3
Date Submitted:
PH. (902) 893-6540 / Fax (902) 895-6684
Sample Submitted by:
Owner
Veterinarian
Mailing Address:
P.O. Box 890, Truro, NS
B2N 5G6
Send Report to:
Owner
Veterinarian
Other
Specify:
How you would like to receive your report (check one)
Email
Fax
Mail
Veterinarian:
Owner Information
Name:
Veterinary Clinic
Farm Name:
Email/Fax:
Address:
Number of Specimens
Sample ID
No. Sent
Specimen Type
No. Received
□_________
_______
Carcass
_______
□_________
_______
Whole Blood
_______
Postal Code:
□_________
_______
Serum
_______
Phone:
Fax:
_______
Urine
_______
□_________
_______
Feces
_______
□_________
Email:
_______
Fresh Tissue
_______
□_________
_______
Fixed Tissue
_______
□_________
_______
Fluid
_______
Premise ID:
_______
Swab
_______
□_________
_______
Peptones
_______
□_________
Farm ID: ______________
Breed: _______________
_______
Fluffs
_______
□_________
_______
Other: ____________ _______
Flock ID:______________
Age: ______□d □w □m □y
□_________
_______
Other: ____________ _______
Flock Code: ___________
Sex: □ M □ F □ Mixed
□_________
_______
Other: ____________ _______
Turkey:
Chicken:
History and Special Requests (additional space on back)
□ Meat
□ Broiler
(presenting illness, clinical signs, treatments, vaccinations, etc)
□ Breeder
□ Broiler-Breeder
□ Small Flock
□ Layer
□ Exhibition
□ Layer-Breeder
□ Small Flock
Farm Population:
□ Exhibition
No. at Risk ____________
□ Hatchery
No. sick
____________
No. Dead ____________
Duration of problem:
_______ □d □w □m □y
Serology
Bacteriology
Parasitology
Pathology
□ MG/MS ELISA
□ AEV-ELISA
□ Aerobic Culture
□ Fecal flotation
□Necropsy
□ CAV-ELISA
□ IBDV-XR-ELISA
□ Histopathology
Aerobic Culture & Sensitivity
□ IBV-ELISA
□ NDV-ELISA
Virology
Other
Salmonella BAX (Fluff)
□ Reovirus-ELISA
□___________
□___________
Salmonella BAX (Peptone)
□ FAdV microneutralization
□___________
□___________
Salmonella BAX (Other)
□______________________
□___________
□___________________
□______________________
LSAD101F3.5
Page 1 of 2
Results derived from testing may be used for statistical surveillance of animal health in Nova Scotia. Laboratory Services complies with the
Federal Health of Animals Act. Laboratory Services will make all reasonable efforts to keep personal information confidential and not disclose
personal identifiers.
History and Special Requests
Laboratory Use Only
Verification of
AHL Lab ID:
receipt in Lab
No. Received in
Specimen Type
Lab
Whole Blood
Serum
Urine
Feces
Fresh Tissue
Fixed Tissue
Fluid
Swab
Peptones
Fluffs
Other:
Other:
Other:
Received in lab by:
Date:
LSAD101F3.5
Page 2 of 2
Results derived from testing may be used for statistical surveillance of animal health in Nova Scotia. Laboratory Services complies with the
Federal Health of Animals Act. Laboratory Services will make all reasonable efforts to keep personal information confidential and not disclose
personal identifiers.
Page of 2