Form LSAD101F15.1 "Swine Submission Form" - Nova Scotia, Canada

ADVERTISEMENT
ADVERTISEMENT

Download Form LSAD101F15.1 "Swine Submission Form" - Nova Scotia, Canada

314 times
Rate (4.3 / 5) 22 votes
AHL LABORATORY ID
Swine Submission Form
Animal Health Laboratory
DATE RECEIVED
NS Department of Agriculture
Physical Address
Date Sampled:
Hancock Building 65 River Rd.
Date Submitted:
Bible Hill, NS B2N 2P3
PH. (902) 893-6540 / Fax (902) 895-6684
Sample Submitted by:
Owner
Veterinarian
Inspector
Other____________
Mailing Address
P.O. Box 890, Truro, NS
Send Report to:
Owner
Veterinarian
Inspector
B2N 5G6
Other _____________________
How you would like to receive your report (check one)
Email
Fax
Mail
Veterinarian:
Owner Information
Name:
Veterinary Clinic:
Farm Name:
Email/Fax:
Number of Specimens
Sample ID
Address:
No. Sent
Specimen Type
No. Received
□ __________
_______
Whole Carcass
_______
□ __________
_______
Whole Blood
_______
Postal Code:
□ __________
_______
Serum
_______
Phone:
Fax:
□ __________
_______
Urine
_______
_______
Feces
_______
□ __________
_______
Fresh Tissue
_______
Email:
□ __________
_______
Fixed Tissue
_______
□ __________
_______
Fluid
_______
□ __________
Premise ID __________________________
_______
Swab
_______
_______
Other: _____________
_______
□ __________
Identification_________________________
_______
Other: _____________
_______
□ __________
Breed
______________
_______
Other: _____________
_______
Sex
Male
Female
□ __________
Age ___ □ days □weeks □months □ years
Herd Information
History and Special requests (additional space on back)
_______Sows
________Boars
(presenting illness, clinical signs, treatments, vaccinations etc)
_______Nursery/Weaner ________Finisher
□ Euthanized Method____________________
Number sick _______________
Number dead _____________
Duration of problem
□ days □weeks □months □ years
Pathology
Bacteriology
Virology
Serology
Parasitology/Other
□ Necropsy
□ Aerobic culture
□ ____________
□ Fecal Flotation
Rotavirus A,B,C PCR
□ ____________
□ ____________
Histopathology
Aerobic culture/
PED/TGE/PDCoV PCR
□ __________
sensitivity
□ _____________
□ ____________
□ ____________
□ Anaerobic culture
□ _____________
□ ____________
□ ____________
□ KIS Test
□ _____________
□ ____________
□ ____________
□ _____________
□ _____________
□ ____________
□ ____________
□ _____________
□ _____________
□ ____________
□ ____________
LSAD101F15.1
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
Swine Submission Form
Animal Health Laboratory
DATE RECEIVED
NS Department of Agriculture
Physical Address
Date Sampled:
Hancock Building 65 River Rd.
Date Submitted:
Bible Hill, NS B2N 2P3
PH. (902) 893-6540 / Fax (902) 895-6684
Sample Submitted by:
Owner
Veterinarian
Inspector
Other____________
Mailing Address
P.O. Box 890, Truro, NS
Send Report to:
Owner
Veterinarian
Inspector
B2N 5G6
Other _____________________
How you would like to receive your report (check one)
Email
Fax
Mail
Veterinarian:
Owner Information
Name:
Veterinary Clinic:
Farm Name:
Email/Fax:
Number of Specimens
Sample ID
Address:
No. Sent
Specimen Type
No. Received
□ __________
_______
Whole Carcass
_______
□ __________
_______
Whole Blood
_______
Postal Code:
□ __________
_______
Serum
_______
Phone:
Fax:
□ __________
_______
Urine
_______
_______
Feces
_______
□ __________
_______
Fresh Tissue
_______
Email:
□ __________
_______
Fixed Tissue
_______
□ __________
_______
Fluid
_______
□ __________
Premise ID __________________________
_______
Swab
_______
_______
Other: _____________
_______
□ __________
Identification_________________________
_______
Other: _____________
_______
□ __________
Breed
______________
_______
Other: _____________
_______
Sex
Male
Female
□ __________
Age ___ □ days □weeks □months □ years
Herd Information
History and Special requests (additional space on back)
_______Sows
________Boars
(presenting illness, clinical signs, treatments, vaccinations etc)
_______Nursery/Weaner ________Finisher
□ Euthanized Method____________________
Number sick _______________
Number dead _____________
Duration of problem
□ days □weeks □months □ years
Pathology
Bacteriology
Virology
Serology
Parasitology/Other
□ Necropsy
□ Aerobic culture
□ ____________
□ Fecal Flotation
Rotavirus A,B,C PCR
□ ____________
□ ____________
Histopathology
Aerobic culture/
PED/TGE/PDCoV PCR
□ __________
sensitivity
□ _____________
□ ____________
□ ____________
□ Anaerobic culture
□ _____________
□ ____________
□ ____________
□ KIS Test
□ _____________
□ ____________
□ ____________
□ _____________
□ _____________
□ ____________
□ ____________
□ _____________
□ _____________
□ ____________
□ ____________
LSAD101F15.1
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 Carcass
Whole Blood
Serum
Urine
Feces
Fresh Tissue
Fixed Tissue
Fluid
Swab
Other:
Other:
Other:
Received in lab by:
Date:
LSAD101F15.1
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