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XXXXXXXX  _         XX AccessionNo.___________    XXCOMPARATIVEPATHOLOGYLABORATORY  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-   \)XXRODENT  =  K (XBB IK  E1HHP X`h!$XE\)SubmissionDate   P     X     Protocolnumber     h  !  $ '[6 1 a  Directchargenumbersrequiredforbilling: DEPTID_____________FUND ` PROGRAMCODE_____  0 PROJECT  ________(ifapplicable)   X InternalWorkOrderNumber:_____________________(ifapplicable)    Nameofdepartmentalbillingofficer( required)  X      ` Telephone   h  !  $     //    & ] Z   88 LabAnimalVeterinarian P  ______Investigator    ____ ` 󀀀Department   h  !  $ Z   Ԍ m  Ќ  ContactPerson   P     X Dept.Address   `      h  !  $  < l   XTelephone P     X Email     `   FAX   h  !  $ ']m   ;   XSpecies     P BackgroundStrain X     _____󀀀Biolevel_______________________   No.______  _󀀀Age P _______󀀀Sex______ X ___󀀀ID   ` __󀀀AnimalRoomNo. h  !  $    SpecimenSubmitted:__________________________________________________________________________________ x  Live A _q _  AԀ    Dead A _q _  AԀ _Euthanized_Ԁ A _q _8  A X 8  Methodanddrugused_________________  Date&timeofDeath__________________  Experimentalprocedures,drugs,dietand/or_transgene_/mutation:   `      h  ! ______ 2      P  _______________________________________________________________________  * ddd Xdd Xdd XH$H$,ZZ,ZZ,ZZ,ZZ+  5+77 5 K(XOJJK Completebackgroundhistoryandlistingofclinicalsigns. _______________________________________________  _________________________________________________________________________________________________ Dt  =33   =K(XK/   SEROLOGY (Circlethedesiredtestortests.) ! n  !___  n" BACTERIOLOGY 6,n$  6K(XJK  ___ 'J%0 'MouseClinicalPanel(9tests)  J&   'J'0 'Tissuesdesired___________________________________ 6,J(  6  YK(XK  H4P X`h!$HHXH ')0 '  YK1HHP X`h!$XK_MHV_,_MVM_Ԁ(_MMV_),_MPV_Ԁ(MPV1,MPV2,MPV3) * NS1,_MNV_,Sendai,M.pul,_TMEV_,_EDIM_  r+   ',0 '___AntibioticSusceptibility 6,-  6K(XNK  ___ 'N.0 'MouseBasicPanel(13tests)  N/   ___ 'N00 ' MYCOLOGY 6,N1  6  <K(XK  H4P X`h!$HHXH '20 '  <K1HHP X`h!$XKClinicalPanelplus_Reo_Ԁ3,LCM,_Ectro_,_PVM_  3   '40 'Tissuesdesired____________________________________ 6,5  6K(XvK  ___ 'v60 'MouseComprehensivePanel(16tests)  v7   ___ 'v80 ' PARASITOLOGY 6,v9  6  K(X"RK  '"R:0 '  BasicPanelplusMAD1,MAD2,_Polyoma_  "R;   '"R<0 '____External___Cecal___Fecal 6,"R=  6K(XK  ___ '>0 'RatClinicalPanel(10tests)  ?   '@0 '____Scotchtapeslide(cleartapeonly) 6,A  6  <K(Xz  K  H4P X`h!$HHXH 'z B0 '  <K1HHP X`h!$XK_RCV_,Sendai,_PVM_,Parvo(NS1),_RPV_,_RMV_,_KRV_, z C H1,M.pul,_TMEV_  &!VD   'z E0 '_____Heartworm_Ԁ____(_Dirochek_)____(Capillary) 6,z F  6K(X! K  ___ '!G0 'RatBasicPanel(12tests)  !H   ___ '!I0 ' VIROLOGY ______________________________(tissue) 6,!J  6K(X~" K  '~"K0 'ClinicalPanelplus_Reo_Ԁ3,LCM  ~"L   ___ '~"M0 ' SKINEXAMINATION 6,~"N  6K(X*#Z K  ___ '*#Z O0 'RatComprehensivePanel(16tests)  *#Z P   ___ '*#Z Q0 ' CYTOLOGY 6,*#Z R  6K(X#! K  '#!S0 'BasicPanelplusMAD1,_CARB_,Han,_Tyzzer_s  #!T   ___ '#!U0 ' HEMATOLOGY 6,#!V  6 K(X$!K  ___ '$!W0 'HamsterClinicalPanel(4tests)  $!X   '$!Y0 'CBC(_RCB_,WBC,_PCV_,Hb,Differential,_platelets_) 6,$!Z  6K(X.%^"K  '.%^"[0 'Sendai,_PVM_,LCM,_Tyzzer_s  .%^"\   '.%^"]0 '(Circleifonlyasingletestdesired.) 6,.%^"^  6K(X% #K  ___ '% #_0 'HamsterComprehensivePanel(7tests)  % #`   ___ '% #a0 ' CLINICALCHEMISTRY 6,% #b  6K(X&#K  '&#c0 'ClinicalPanelplusSV5,_Reo_Ԁ3,E._cun_  &#d   '&#e0 'SpecificTest(s)___________________________________ 6,&#f  6K(X2'b$K  ___ '2'b$g0 'GuineaPigClinicalPanel(4tests)  2'b$h   '2'b$i0 'SmallAnimalPanel___________ 6,2'b$j  6K(X'%K  ''%k0 'Sendai,_PVM_,E._cun_,P13  '%l   ___ ''%m0 ' URINALYSIS 6,'%n  6K(X(%K  ___ '(%o0 'GuineaPigBasicPanel(7tests)  (%p   ___ '(%q0 ' NECROPSY 6,(%r  6K(X6)f&K  '6)f&s0 'ClinicalPanelplusSV5,LCM,_Tyzzer_s  6)f&t   ___ '6)f&u0 ' _HISTOPATHOLOGY_ 6,6)f&v  6K(X)'K  ___ ')'w0 'GuineaPigComprehensivePanel(8tests)  )'x   ')'y0 ' H4P X`h!$HHXH(tissue)________________________________________ 6,)'z  6 K1HHP X`h!$XKK(X*'K  ___ '*'{0 'BasicPanelplus_GPCMV_  *'|   ___ '*'}0 ' _PHENOTYPING_ 6,*'~  6K(X:+j(K  ___ ':+j(0 'PCRASSAY  :+j(   ':+j(0 'Targettissueororgansofspecialinterest______________ 6,:+j(  6K(X+)K  '+)0 '____Helicobacter_ԀPCR  +)   '+)0 ' 6,+)  6K(X,)K  ',)0 '///    & / >  /____MHV_>?  >Ԍ////   ,)   ___ ',)0 ' OTHER 6,,)  6 K(X>-n*K  '>-n*  '___Other_____________________________________  >-n*   '>-n*0 ' 6,>-n*  6K(X-+K  '-+0 '  -+   '-+0 ' 6,-+  <6K(X.+K  '.+0 '  .+   '.+0 ' $.+ <  $XX/K(XB/r,KCHARGES:   P     X   AnimalWeight________________ B/r, _ 9 XX',?XX 9