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Accession No.___________ COMPARATIVE PATHOLOGY LABORATORY Research Animal Resources Center, 389 Enzyme Institute 1710 University Avenue, University of Wisconsin Madison, WI 53726-4087 Clinical Lab 608/263-6464 • Histo Lab 608/262-0933 • FAX 608/265-2698 AQUATIC SPECIES Submission Date Protocol Number Direct charge number required for billing: DEPT ID FUND PROJECT (if applicable) Internal Work Order Number: Name of departmental billing officer (required) Lab Animal Veterinarian Investigator Contact Person Dept. Address Telephone Email Species Strain/Breed No. Age Sex ID Specimen Submitted: Live Dead Euthanized PROGRAM CODE (if applicable) Telephone Department FAX Bio level Animal Room No. Method and drug used Date & time of Death Experimental procedures, drugs, diet and/or transgene/mutation: History Freshwater:_____ Marine______ System Size:______gal How long has system been setup? __________________ Water source____________________ Number of animals in system____ Temperature__________ Water appearance________________ Last water change_________ Appearance/behavior/appetite change, etc. Recently, have more animals of a similar age and/or class died showing similar signs of illness (if “yes” explain)? Is there any new introductions and when? Are there any new introductions (if so when)? Treatments and Dates: Water Quality DO: _____________ mg/l Temp.___________ pH ____________ Ammonia ________ mg/l Nitrites _________ mg/l Salinity _________ ppt Hardness _________ mg/l Alkalinity _________ mg/l Chlorine __________ mg/l TESTS DESIRED __ __ __ __ BACTERIOLOGY Tissues desired ___________________________________ ___ HISTOPATHOLOGY (tissue)____________________________________________ ___Antibiotic Susceptibility ___ NECROPSY MYCOLOGY Tissues desired___________________________________ PARASITOLOGY ____External ___Fecal ______ Gills “SKIN” EXAMINATION ___ CYTOLOGY ___ OTHER___________________________________________ CHARGES: Animal Weight _______________
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