health monitoring submission form - charles river laboratories€¦ · health monitoring submission...
TRANSCRIPT
New customers, write NEW in this field. Existing customers can find their LTM customer ID# in the header of result reports from previous submissions. Need help? Contact [email protected].
Are these animal individually identified?
Are these animals immunodeficient?
Ship Date:
Total Number of Animals:
Date:Signed:
To the best of my knowledge these animals and/or specimens do not contain any infectious agent or material which might pose a threat to human health. If this is not the case, please call Charles River before sending animals.
Animal Information
Protocol:
Species:
Health Monitoring Submission Form
To be completed at Charles River
LTM Order Number: Date Received:
Helicobacter PCR MPV PCR MNV PCR Pneumocystis PCRAdditional services: Other
Page 1 of 2
Please use one form per SPECIES.
Please include a copy of Pages 1 and 2 (if used) with the container in which your animals are shipped. For more than 25 animals for one protocol, please include additional copies of page 2.
Are you submitting these animals as a diagnostic case due to illness? If yes, please also fill out and include the Diagnostic Case Workup Questionnaire with your animal(s).
Animal # Animal ID or Group ID Quantity
in Group Strain Age or Date of Birth Sex Markings (ear marks,
tags, etc.)
1
2
3
4
5
6
7
8
9
10
Customer Information Same as Customer* = required
PO #
Payment information required at the time of submission.
Contact
Phone To pay with a CC on file, indicate the last four (4) digits and expiration date. For CC security, do not write the full CC number.
Email*
Phone*
Zip Code*State*
City*
Address 2
Address 1*
Institution*
Contact*
Bill To Information
Email*
Phone*
Zip Code*State*
City*
Address 2
Address 1*
Institution*
Contact*
Pay by Credit Card (CC)
Pay by PO
CC Last 4 Digits
CC Exp Date
PLEASE NOTE: If you generate summarized health reports from LTM, orders must be created directly in LTM for your samples to be associated with specific colonies. If you have questions or need help getting started, please contact [email protected].
LTM Customer ID#*
Instructions to lab:
Notes:
If you answered yes to the identification question, please enter the identifying characteristic into the "Markings" column in the table below and on page 2.
Animal # Animal ID or Group ID Quantity
in Group Strain Age or Date of Birth Sex Markings
(ear marks, tags, etc.)
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Notes:
Institution:
Page 2 of 2Please include a copy of Pages 1 and 2 (if used) with the container in which your animals are shipped.
For more than 25 animals for one protocol, please include additional copies of page 2.
Shipping Instructions
Questions? [email protected] www.criver.com/info/dx
Live animals for Health Monitoring must be scheduled with the Diagnostic Laboratory prior to shipping. Please contact the Lab Services team at [email protected] to schedule live animal submissions. Animal Submission: Place a copy of pages 1 and 2 (if used) with your live animal shipping container. Please follow International Air Transport Association (IATA) guidelines. Use a carrier experienced with live animal shipments that has temperature controlled vehicles. Charles River provides IATA-compliant live animal shipping materials free of charge; visit www.criver.com/shippingmaterials to request shipping materials online. Submit your animals to Charles River:
Charles River RADS 327 impasse du Domaine Rozier Domaine des Oncins 69210 SAINT GERMAIN NUELLES FRANCE
Charles River RADS Health Monitoring Lab 261 Ballardvale Street Building 22 Loading Dock Wilmington, MA 01887 USA
LTM Customer ID#*