AVDL Form CF.ACC.1.10 "General Submission Form" - Alabama

What Is AVDL Form CF.ACC.1.10?

This is a legal form that was released by the Alabama Department of Agriculture and Industries - Alabama Veterinary Diagnostic Laboratory - 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, 2020;
  • The latest edition provided by the Alabama Department of Agriculture and Industries - Alabama Veterinary Diagnostic Laboratory;
  • 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 AVDL Form CF.ACC.1.10 by clicking the link below or browse more documents and templates provided by the Alabama Department of Agriculture and Industries - Alabama Veterinary Diagnostic Laboratory.

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Download AVDL Form CF.ACC.1.10 "General Submission Form" - Alabama

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AVDL
Alabama Veterinary
ACCESSION #:
Diagnostic Laboratory System
Regional Lab
Auburn Lab
DATE
www.labs.alabama.gov
RECEIVED:
CASE
 Thompson Bishop Sparks
 Mitchem-Sparks
 Hinton Mitchem
 J. B. Taylor
Poultry Diagnostic Lab
State Diagnostic Lab
Diagnostic Lab
Diagnostic Lab
COORDINATOR:
1001 Industrial Dr
890 Simms Rd.
1833 Industrial Blvd
495 State Road 203
CHARGE
N/C PAID: $
CASH
CHECK #
Hanceville, AL 35077
Auburn, AL 36832
Boaz, AL 35957
Elba, AL 36323
Ph: (256) 352-8036
Regional Lab
Auburn Lab
Ph: (334) 844-4987
Ph: (334) 897-6340
Ph: (256) 593-2995
Tech Initials
Tech Initials
Fax: (256) 352-8038
Fax: (334) 844-7206
Fax: (334) 897-0272
Fax: (256) 593-2996
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:
Vet
Own
Other:
Bill to:
Vet
Own
Other:
email
fax
mail
email
fax
mail
Report preference:
Bill preference:
Results will be shared only with client(s) checked in the "Report to" section; however, results may also be shared with the vet/clinic listed unless client requests
otherwise. 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 Name or ID
Species
Breed
Test sections
Lab Use Only
Necropsy
________________
Sex
Age
Practitioner
________________
Years
Months
Days
Necropsy
________________
History
:
Branch Lab Tests
(diet, vaccine, nutrition, illnesses, herd, etc.)
Disposal Only
________________
(Lab Use Only)
Histopathology
________________
Necropsy
Bacteriology
________________
Clinical signs/symptoms:
Practitioner
Mycology
________________
Necropsy
Virology
________________
Bacteriology
Recent changes
:
(diet, herd, travel, etc)
Molecular/PCR
________________
Mycology
Serology
________________
Serology
Toxicology
________________
Treatment/Medications:
Rabies, ADPH
Parasitology
________________
USDA
Rabies, ADPH
________________
BSE
Diagnosis/differentials:
AUCVM
________________
Scrapie
CWD
________________
HOLD
BSE
________________
#Herd
#Sick
#Dead:
Scrapie
________________
Parasitology
Test request(s):
HOLD
________________
Other:
Check back of form for test selection or write in space above. If no tests are
Other:
________________
requested, tests will be performed at the discretion of the pathologist. Necropsy
fees include all in-house tests performed.
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.1.10
NOV 2020
KS
1 of 2
AVDL
Alabama Veterinary
ACCESSION #:
Diagnostic Laboratory System
Regional Lab
Auburn Lab
DATE
www.labs.alabama.gov
RECEIVED:
CASE
 Thompson Bishop Sparks
 Mitchem-Sparks
 Hinton Mitchem
 J. B. Taylor
Poultry Diagnostic Lab
State Diagnostic Lab
Diagnostic Lab
Diagnostic Lab
COORDINATOR:
1001 Industrial Dr
890 Simms Rd.
1833 Industrial Blvd
495 State Road 203
CHARGE
N/C PAID: $
CASH
CHECK #
Hanceville, AL 35077
Auburn, AL 36832
Boaz, AL 35957
Elba, AL 36323
Ph: (256) 352-8036
Regional Lab
Auburn Lab
Ph: (334) 844-4987
Ph: (334) 897-6340
Ph: (256) 593-2995
Tech Initials
Tech Initials
Fax: (256) 352-8038
Fax: (334) 844-7206
Fax: (334) 897-0272
Fax: (256) 593-2996
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:
Vet
Own
Other:
Bill to:
Vet
Own
Other:
email
fax
mail
email
fax
mail
Report preference:
Bill preference:
Results will be shared only with client(s) checked in the "Report to" section; however, results may also be shared with the vet/clinic listed unless client requests
otherwise. 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 Name or ID
Species
Breed
Test sections
Lab Use Only
Necropsy
________________
Sex
Age
Practitioner
________________
Years
Months
Days
Necropsy
________________
History
:
Branch Lab Tests
(diet, vaccine, nutrition, illnesses, herd, etc.)
Disposal Only
________________
(Lab Use Only)
Histopathology
________________
Necropsy
Bacteriology
________________
Clinical signs/symptoms:
Practitioner
Mycology
________________
Necropsy
Virology
________________
Bacteriology
Recent changes
:
(diet, herd, travel, etc)
Molecular/PCR
________________
Mycology
Serology
________________
Serology
Toxicology
________________
Treatment/Medications:
Rabies, ADPH
Parasitology
________________
USDA
Rabies, ADPH
________________
BSE
Diagnosis/differentials:
AUCVM
________________
Scrapie
CWD
________________
HOLD
BSE
________________
#Herd
#Sick
#Dead:
Scrapie
________________
Parasitology
Test request(s):
HOLD
________________
Other:
Check back of form for test selection or write in space above. If no tests are
Other:
________________
requested, tests will be performed at the discretion of the pathologist. Necropsy
fees include all in-house tests performed.
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.1.10
NOV 2020
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
Herpes (FVR-1) FA
Parainfluenza 3 FA
Kidney
Fungal culture
Kidney
Panleukopenia virus FA
BVD Ear Notch ELISA
Spleen
Brucella culture
Spleen
Sm. Intestine
Salmonella culture
Brain
Canine
Ovine/ Caprine
Lg. Intestine/Cecum
Campylobacter culture
Small intestine
Coronavirus FA
Contagious ecthyma
Brain
Johne’s culture
Lymph node
Adenovirus FA
FA
Muscle
Listeria culture
Ear notch
Lymph Node
Listeria cold enrichment culture
Retropharyngeal
Cervid
Multiple species
Urine
(brain only)
lymph nodes
CWD ELISA*
Rotavirus ELISA
Feces
Other:
(fresh)*
Other:
Swab
Stains
Obex (whole,
Abscess/Lesion
Cryptosporidium: Auramine-O
fresh)*
Instructions:
acid fast stain
Ear tag w/skin*
Cytology/impression
Blackleg: Fluorescent antibody
Feces
slide
Other:
_
Swab:
Other:
Instructions:
Other:
*CWD sampling procedures
must be followed. Please
call with questions.
Toxicology
Molecular/PCR
Specimen
Tests
Specimen
Bovine/Ovine/Caprine
Canine
Liver
Cyanide
Potassium
Lung
BRSV
Herpesvirus
¥
Kidney
Ethylene glycol
Selenium
Liver
BVDV
Parvovirus
Stomach contents
Insecticide
Salt
Kidney
IBR
Distemper virus
(feed only)
Serum
screen
Spleen
Mycoplasma**
Influenza
Zinc
¥
Blood
Rodenticide
Brain
Bluetongue
Mycoplasma**
Nitrate & Nitrite
Vitreous Humor
screen
Intestine
Chlamydia**
pH
Aqueous Humor
Strychnine
Lymph node
Tritrichomonas
Feline
Mycotoxins
(feed only):
Feed
Arsenic
Blood in EDTA
(bovine only)
Coronavirus (FCoV)
Aflatoxin
Hay
Cadmium
(BVD, BT only)
Chlamydia**
Deoxynivalenol
¥
Other:
Calcium
Swab:
Porcine
Mycoplasma**
Fumonisin B1
Phosphorus
___
PEDV
Influenza
Ochratoxin
Instructions:
Chromium
Other:
Swine influenza
Ionophores
Copper
¥
Mycoplasma**
Equine
(feed only)
¥
Iron
Instructions:
EEE
(sent to NVSL)
Feed visual exam
Lead
¥
Cervid
EHV-1
Bone ash
§
¥
Magnesium
Bluetongue virus
Urolith analysis
WNV**
EHDV
Other:
EVA
Mycoplasma**
Influenza
Please submit liver,
kidney, and stomach or
¥
Special blood/serum
rumen contents on all
Limited testing;
sampling tube required;
necropsies when
call for more
please call 334-844-
*
*Available on
Toxicology is
information
7251 for details
multiple/other species
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 VN
Spleen
Tonsil
U. bladder
EHV-1
§
Ovine progressive
IBR
Lymph Node
Adrenal
Other:
WNV
pleuropneumonia
Neosporosis
Thymus
Thyroid
Other:
Johne’s disease
Leptospirosis panel
Muscle
Uterus
Multiple Species
(caprine)
Bovine respiratory panel
Bone marrow
Umbilicus
Leptospirosis panel
BVDV VN
Bluetongue
Canine
IBR
Brucella abortus/suis
Brucella canis
PI-3
Leptospirosis panel
BRSV
Instructions:
Parasitology
Bovine leukosis virus
Fecal flotation
(centrifugation)
Feline
Johne’s disease
Zinc Sulfate Flotation
FELV
IgG (passive transfer)
McMasters Egg Count
FIV
BVDV antigen capture
Coronavirus (FCoV)
ELISA (PI)
Please note this EHV-1 test will not differentiate neurologic form from respiratory form; please call for more information.
§
Indicate all submitted samples and the appropriate test section(s).
AVDL Submission Form CF.ACC.1.10
NOV 2020
KS
2 of 2
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