primary submitter: karen moore; jaimie...

Enhanced Surveillance for Equine Arbovirus Disease ProjectRequest for Laboratory Examination – INITIAL / FIRST VISIT

OWNER Name:

Property Name …………………………………………………….

PIC Property address/geographic location of affected animals

....................................................................................... Postcode

Phone (….)………………………………………Fax (….) …………………………………………………….

Email: ……………………………………………………….

Office OnlyHerd No.

Date of Investigation

…..../….../…...

PRIMARY SUBMITTER: Karen Moore; Jaimie Hunnam

INVESTIGATOR/VETERINARIAN

Name:……………………………………………………………………………………..……………………………………..

Practice or District Office Name: …………………………………………..……………………………………………………………….

Postal Address:…………………….................................................................................................... Postcode…………………

Phone (….) ……………………….. Fax (….) …………………………….. Email: …………………………………………………..

Species

EQUINE

Breed

………………………

Age

………………….……

Sex

………………….……

Total No. Sick

…….………………

Total No. Dead

…….……………Additional history/Comments

……………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………

Number and nature of samples(tick and indicate number of samples)

Investigations required

Blood (Whole) x Hendra PCR Arbovirus panel (Ross River, pan-flavivirus serology (MVEV, Kunjin virus if indicated)) Blood (EDTA) x

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Enhanced Surveillance for Equine Arbovirus Disease Project – Request for Laboratory ExaminationCLINICAL ASSESSMENT OF SAMPLED ANIMALS

Animal name Microchip number Rectal temperature Samples collected(tick)

Blood: EDTA □ Whole □

Blood: EDTA □ Whole □

Blood: EDTA □ Whole □

Blood: EDTA □ Whole □

Blood: EDTA □ Whole □

Blood: EDTA □ Whole □

Please forward samples to – Veterinary Diagnostic Services, AgriBio Specimen Reception, 5 Ring Road, La Trobe University Bundoora, Victoria, 3083 Phone: (03) 9032 7515Fax: (03) 9032 7604 Email: vet.diagnostics@ecodev.vic.gov.auFor more information please contact the duty pathologist on (03) 9032 7515

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