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Serology Requisition Form

Instructions: All fields marked with an * are required.
Complete form. Click printer icon (top right of page). Select printer: Adobe PDF. Save and e-mail the PDF as an attachment to Rada.Norinsky@rockefeller.edu.

RS Numbers(s):   *
Investigator:   *
Date:   *
Institution/Lab:   *
Phone/Fax:   *
Address/Box (to which results should be sent):   *
Billing  
Name:   *
Account# (*full PTAEO required!)
(Project/Task/Award/Expenditure/Org):
  *
P.O. / Address:   *
ANIMAL TEST REQUESTS: (please fill in test request no. below, i.e. 1a)
  1. mouse
    1. core panel-(Sendai, PVM, MHV, LCM, Mycoplasma, MVM, GDVII, EDIM)
    2. extended panel- (core panel + K virus, Polyoma, Madeno, Ectromelia, Reo-3)
    3. orphan parvovirus
    4. Hantaan virus
    5. specified test(s)
  2. rat
    1. core panel-(Mycoplasma, Sendai, SDAV/RCV, PVM, LCM)
    2. extended panel- (core panel + H1, Reo-3, KRV)
    3. CAR Bacillus
    4. specified test(s)
  3. guinea pig/hamster
    1. core panel-(Sendai, SV5, PVM, Reo 3, LCM)
    2. specified test(s)
  4. rabbit
    1. Encephalitozoon cuniculi
    2. CAR Bacillus
    3. Clostridium piliforme
  5. cat
    1. FeLV
    2. FIV
  6. primate
    1. Ebola virus
    2. Herpes simiae virus
  7. other tests
Animal #1
I.D. Number:   *
RS Number (lab use):   *
Species/Strain:   *
Test No.:   *
Dilut./Heat Inact.:   *
Animal #2
I.D. Number:  
RS Number (lab use):  
Species/Strain:  
Test No.:  
Dilut./Heat Inact.:  
Animal #3
I.D. Number:  
RS Number (lab use):  
Species/Strain:  
Test No.:  
Dilut./Heat Inact.:  
Animal #4
I.D. Number:  
RS Number (lab use):  
Species/Strain:  
Test No.:  
Dilut./Heat Inact.:  
Animal #5
I.D. Number:  
RS Number (lab use):  
Species/Strain:  
Test No.:  
Dilut./Heat Inact.:  


Instructions: (All fields are required unless otherwise specified.)
Complete form. Click printer icon (top right of page). Select printer: Adobe PDF. Save and e-mail the PDF as an attachment to Rada.Norinsky@rockefeller.edu.