Download Sample Submission Form for Disease Investigation (DI)

SAMPLE SUBMISSION FORM FOR DISEASE INVESTIGATION For, The Assistant Director Disease Investigation Laboratory Directorate of Animal Husbandry Shimla­171005 Q +91 94180 85640 Q +91­177­2830164­Extn 231 ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­Veterinarian/Case Coordinator: Name of Hospital/ Dispensary/ Farm: District: QPhone: For Lab Use Only Lab ID Number: Samples Received Sample Condition: D Optimal D Sub­optimal D Non­diagnostic Sample Shipped via: D Messenger D Courier D Other OPD No. Owner's Name and Address Animal ID: Species Sex: Age: Samples Submitted: Date of Collection: Tests Requested: D Haemogram (Complete Blood Count­CBC) Hb, PCV, ESR TLC, DLC, MCV, MCH, MCHC, Haemoprotozoa D Faecal Sample D Skin Scrapping D Urine Test D Urine­Culture D Antibiotic Sensitivity D Milk­Mastitis / Milk­Culture D Pullorum­Testing D Brucellosis SAT/RBPT D TB Test D JD Test D Impression Smear Cytology D Biopsy D Necropsy D Histopathology D Biochemistry Tests Glucose, Liver Fn, Ca, P, etc., Renal Fn. Cholesterol D Other Tests (pl. specify) DI reserves right to modify the tests requested for efficient case workup. Additional History, Vaccination status, treatment etc: Condition(s) suspected: Certified that the specimen(s) submitted along have been collected by me from the animals described on the date indicated. Veterinarian's / Case Coordinators Signature