ULAM In-Vivo Animal Core External ADL Testing Submission ......View ULAM Rates Email completed form to [email protected] Email: [email protected] UPS/FedEx charges and/or processing

In-Vivo Animal Core (IVAC) Animal Diagnostic Laboratory External Testing Submission Sample Drop-off Locations: IVAC Use Only

Monday – Friday, 9:00 AM – 3:00 PM3527 Animal Research Facility 1150 W. Medical Center DriveAnn Arbor, MI 48109-0614 ARF Phone: (734) 936-3803

Monday – Friday, 9:00 AM – 4:00 PM North Campus Research Complex 2800 Plymouth Road B36/G154 Ann Arbor, MI 48109-2800 NCRC Phone: (734) 936-3395

Date In: Date Out:

Accession #: Technician:

Short Code / Programmatic Area: Investigator: Department:

Lab Contact: Phone: Email:

Animal Identification: Any experimental treatments that could affect results:

Species: Animal Location: Sample Source(s):

(Herpes B testing) Primate bite/scratch exposure: (Microbiology) Antibiotic use in last 72 hours: Yes No

Type of injury and date: Type of antibiotic: Exposed human’s name:

Animal Clinical Number: Submitted By:

Clinician: Resident: Vet Tech:

Clinical Summary / Differential Diagnosis:

Microbiology Service QTY Clinical Pathology Service QTY Surveillance Testing Service QTY General Culture and Susceptibility (95017) Cortisol, resting (T445) PCR UM Mouse

Surveillance PRIA (L-01) General Culture (95016) Fecal Occult Blood (T180) PCR GVA (L-03) Anaerobic Culture (95004) *Starplex transport media REQUIRED,see Vet Tech Staff*

Mycoplasma Culture (95024) PCR Helicobacter (L-04)

Blood Culture (95005) *Blood collection bottles REQUIRED,see ADL staff*

PT/PTT (T415) PCR Helicobacter Profile (RA-03)

Fungal Culture (95015) Qualitative fecal (60011) PCR MNV (L-05) Fecal Culture and Susceptibility (95014) Urine Protein/Creatinine Ratio (T775) PCR Pinworm (L-06) C. Difficile ELISA (60063) PCR Mycoplasma Ovid (60073) PCR Fur Mite (L-07) C. Perfringens ELISA (60062) PCR Porcine Circovirus Type 2 (90043) PCR (L-08) Urine Culture and Susceptibility (95032) PCR – 5 Tests (L-09) Mycoplasma Culture (95024) Primate Virology Service QTY Other testing: Herpes B Cell Culture (HB-01)

Herpes B Serology Antibody (HB-02)

Date shipped: Tracking #: PCR SRV (P00001)

View ULAM Rates Email completed form to [email protected]

Email: [email protected]

UPS/FedEx charges and/or processing fees may apply. Updated: 8/11/2020