Submission Form - Veterinary Diagnostic Laboratory - University of ...

Phone: (612) 625-8787Fax: (612) 624-8707Toll Free: 1-800-605-8787E-mail: vdl@umn.eduWeb site access/results:www.vdl.umn.eduRuminant Health Test ChartContact Information - Owner/ProducerOwner NameCompanyAttending VeterinarianVeterinarianClinicFor officeuse onlyAddressAddressCityStateZipCityStateZipPhoneFaxPhoneFaxEmailEmailAnimal/LocationSite/FarmPremises/Reference IDCountryRegulatory Premises IDState ZipCountySpeciesResult Reporting and BillingAffiliate (list codes)PhoneFaxEmailBill: Vet/Clinic OtherFor Lab Use OnlySample /Specimen Arrived:Live Rm Temp Frozen Cold PkFixed Other_____________________Please complete animalidentification information on page 2SerologyTest Samples:Mycobacterium paratuberculosisTest Samples:Anaplasmosis (ELISA)...............................................................Blue Tongue (AGID)..................................................................Blue Tongue (ELISA)................................................................Bovine Adenovirus (SN).............................................................Bovine Herpes Mammalitis virus/BHV-2 (SN)............................Bovine Herpes-4/DN599 (IFA)...................................................Bovine Leukosis (AGID)...........................................................Bovine Leukosis (ELISA)...........................................................Bovine Parainfluenza-3 (HI).......................................................Bovine Parvovirus (HI)..............................................................Bovine Respiratory Syncytial Virus (SN)...................................Bovine Viral Diarrhea Virus Antibody........................................Serum Neutralization (SN), Types 1 and 2.........................Brucella abortus- BAPA Card RAP RIV...........FPA SPT STT .......................CAE-Caprine Arthritis Encephalitis (AGID)...............................CAE-Caprine Arthritis Encephalitis Elitest (ELISA)...................Chronic Wasting Disease (ELISA)-tissue..................................Coxiella burnetii - Q Fever (ELISA)...........................................Epizootic Hermorrhagic Disease (AGID)...................................Infectious Bovine Rhinotracheitis/BHV-1 (SN)..........................IgG/IgM, total (zinc sulfate turbidity).........................................Leptospira sp., 6 serovars (MA)................................................Neospora (ELISA).....................................................................Ovine Progressive Pneumonia (AGID)......................................Ovine Progressive Pneumonia /MVV Elitest (ELISA).............Toxoplasma gondii (latex agglutination)...................................Vesicular Stomatitis (SN) New Jersey Indiana.............OtherMycobacterium paratuberculosis-Johne's (Culture) Feces........................................Mycobacterium paratuberculosis-Johne's (Biocor ELISA)...............................................Mycobacterium paratuberculosis-Johne's (ELISA)..........................................................Mycobacterium paratuberculosis-Johne's (PCR) Feces............................................*Pre-pooled samples not accepted*PCR samples must be shipped on cold packsMolecular Diagnostic Tests (PCR):BVD (PI detection)Serum Tissue......................................................BVD (Small Ruminants) - Purple top/EDTA tube.............................................................Freemartin PCR - Purple top/EDTA tube.........................................................................BVD Sequencing Serum Isolate sample..................................................Rotavirus PCR Feces Fecal swabs Nasal swabs TissueIsolate FeedbackEnvironement ...............................Bovine Coronavirus Tissue Feces Fecal swabsTracheal lavage Nasal swabs......................................BRSVTissue Nasal swabs Isolate Tracheal lavage...........BHV-1/IBR Tissue Nasal swabs Tracheal lavage Vaginal fluidConjunctival swab Vaginal swab Isolate Skin swab....VirologyBovine Viral Diarrhea Virus Antigen (PI detection)l..........................................................IDEXX Antigen Capture ELISA (ACE)....................................................................(Fresh ear notch sample ONLY)Reasons for TestsPrivate Sale Diagnostic Test ExhibitionExport toOtherMycobacterium paratuberculosis (Johne's) Sample(s):Johne's-new herd.........................................Johne's-status herdMaintain levelAdvance to levelJohne's-management herd...........................Johne's-demonstration herd.........................Johne's-fecal follow up.................................SYS.FORM.063, Rev. 4, 11/20/2013 Page 1

Veterinary Diagnostic Laboratory - University of MinnesotaRuminant Health - Animal IdentificationAnimal DemographicsCommentsDate BledFor officeuse onlyNumber of SamplesSignatureBreed LotSample # Animal ID Age Gender BreedSample # Animal ID Age Gender Breed123313233456789101112131415161718192021222324252627282930SYS.FORM.063, Rev. 4, 11/20/2013343536373839404142434445464748495051525354555657585960Page 2