WPC& zE&0AP5B&HkjKO:X(ckх.jμuO3⤁[]ͦ$s;C5'YXZkoPfΡ0)A@;#dOl4VNTc(my9%5Bf=h5,;-f䆓d y- 3 S2 kb9#z IȁBzXݯ\"3b*XM׵|)H xl 6uZ0YbO3} ;*s3l)lqe!>-gJ4b ~$J~GBw4䞾ui6V|4ţ-YȾP?`wS/A:TOO͕kbT8$KTÇohN" ۀUA HS|dTJ;kG(?RaL &(AxlM4O6}.lU* 0jU. 0~ 0$2 0hV B B B B D32 U 2e f a D+  0 # UNg %M(N^ w4  m\  `Times' Accession No RARC,0RARC UW - Madison .   Hl [4Heading 1Heading 1C<6X9`(CourierC   XXX?\  `Times? <6X9`(CourierH 4Heading 2Heading 2       H_ p4Heading 3Heading 3  ,   ,"t t h!$,      J@HHP X`h!$J  h:Default ParaDefault Paragraph Font d d d d 'dxdKr`WingdingsTable_A'dxd#|x(X$HH..      X XXXX XXX  0&d9 Z6Times New Roman RegularX8Z Aq5SF\XfeU X!HH..      X XXXX XXX   _         tXX  AccessionNo.___________    X XtCOMPARATIVEPATHOLOGYLABORATORY  ResearchAnimalResourcesCenter,389EnzymeInstitute u      &    1710UniversityAvenue,UniversityofWisconsinB  Ԍ [ Ќ   Madison,WI537264087 Aq   ,  6"t t h!$X6    H%t t `h!$tt XH  ClinicalLab608/2636464@..@.._Histo_ԀLab608/2620933@..@..FAX608/2652698  Ԍ 'W Ќ ,  - Xtt `X-   ]XX NONHUMANPRIMATE  =  K (XBB IK  E1HHP X`h!$XEt]SubmissionDate   P     X     Protocolnumber     h  !  $ '[6 1 a  Directchargenumberrequiredforbilling :DEPTID____________FUND ` _____PROGRAMCODE_____  0 PROJECT  _______(ifapplicable)   X InternalWorkOrderNumber:_____________________(ifapplicable)    Nameofdepartmentalbillingofficer( required)  X      ` Telephone   h  !  $     ޷t޷    & ] _   8Mt8M LabAnimalVeterinarian P  ______Investigator  _________ `   Department h  !  $ _   Ԍ m  Ќtttt  ContactPerson   P    ___Dept.Address   `      h  !  $  < l   XTelephone P    Email X     ________  FAX   h  !  $ ']m   ;   XSpecies     P  󀀀CommonName______________________   No._________󀀀Age P _______󀀀Sex__ X ____󀀀ID   ` ___󀀀AnimalRoomNo. h _________ $    Biolevel  ____________󀀀Isthisanimal_SIV_Ԁ+?Yes E t_q _t  E  No E t_q _t  EԀ ` BVirus+?Yes E t_q _t  E h No E t_q _t  E x   IsthereaBVirushumanexposure? Yes E t_q _t  EԀ X No E t_q _t  E Gw SpecimenSubmitted:__________________________________________________________________________________ F Live E t_q _t  EԀ  Dead E t_q _t  EԀ _Euthanized_Ԁ E t_q _t  EԀ X   Methodanddrugused_______________ Dt Date&timeofDeath______________________________________ r Experimentalprocedures,drugs,dietand/or_transgene_/mutation:   `      h ________ $   * ddd Xdd Xdd XH$H$,wZZ,KZZ,ZZ,ZZ,ZZ+  5+ 5 K(XJJKI t t ICompletebackgroundhistoryandlistingofclinicalsigns._______________________________________________ o I tt I_________________________________________________________________________________________________  _________________________________________________________________________________________________ Eu  ޷t =34!   =K(XKPrimate ! " !  ___ '#0 ' VIROLOGY ______________________________(tissue) :0$  :K(XK  ___ * %0 *_Retrovirus_ԀPanel  &   ___ ''0 ' SKINEXAMINATION :0(  :K(X=mK  ___ * =m)0 *_SIV_,_SRV_,_STLV_,Foamy  =m* ___  =m+  CYTOLOGY :0=m,  :K(XK  ___ * -0 *BVirus  .  ___  / HEMATOLOGY :00  :K(XK  ___ * 10 *Other_______________________________________  2   3 CBC(_RCB_,WBC,_PCV_,Hb,Differential,_platelets_) :04  :K(XAqK  ___ * Aq50 * PCRASSAY  Aq6   Aq7 (Circleifonlyasingletestdesired.) :0Aq8  :K(XK  * 90 *____Helicobacter_ԀPCR  :   ___ ';0 ' CLINICALCHEMISTRY :0<  :K(X K  *  =0 *Other   >   ' ?0 'SpecificTest(s)___________________________________ :0 @  :  <K(XE!u K  H4P X`h!$HHXH * E!uA0 *  <K1HHP X`h!$XK  E!uB   'E!uC0 'SmallAnimalPanel________ :0E!uD  :K(X!! K___ ! !!E !BACTERIOLOGY  !!F   ___ '!!G0 ' URINALYSIS :0!!H  :K(X" K  * "I0 *Tissuesdesired________________________________  "J   ___ '"K0 ' NECROPSY :0"L  :K(XI#y K  * I#y M0 *___AntibioticSusceptibility  I#y N   ___ 'I#y O0 ' _HISTOPATHOLOGY_ :0I#y P  :K(X#%! K  ___ * #%!Q0 * MYCOLOGY  #%!R   '#%!S0 ' H4P X`h!$HHXH(tissue)________________________________________ :0#%!T  : K1HHP X`h!$XKK(X$!K  * $!U0 *Tissuesdesired_________________________________  $!V   ___ '$!W0 ' BVirusexposure :0$!X  :K(XM%}"K ! M%}"Y !  'M%}"Z0 'Swabs(source)___________________________________ 6,M%}"[  6K(X%)#K  __ +!%)#\0 + PARASITOLOGY ! %)#] !  '%)#^0 'Serum_________________________________________ 6,%)#_  6K(X&#K  +!&#`0 +____External___Cecal___Fecal ! &#a !  '&#b0 ' 6,&#c  6K(XQ'$K  +!Q'$d0 +____Scotchtapeslide(cleartapeonly) ! Q'$e !  'Q'$f0 ' 6,Q'$g  6K(X'-%K  +!'-%h0 +_____Heartworm_Ԁ____(_Dirochek_)____(Capillary) ! '-%i !  ''-%j0 ' 6,'-%k  6K(X(%K  +!(%l  +޷޷޷    &  3  3 4  3Ԍ޷  ! (%m !  '(%n0 '$(%o   $K(XU)&KI ޷'(4X X I CHARGES:   P     X   AnimalWeight______________ *'q