Comparative Pathology Laboratory

CPL Request for Laboratory Examination

CPL# / # Animals: /

# Samples & Type:

Species: / Date of Birth: / Sex: / Collection Date:
Strain / Breed / Cell Line: / Received CPL Date:
Animal ID: / Investigator: /
UC Recharge#:
Department:
/
Building:
/
Room:
/
Rack:
Email:
Phone: / Purchase Order: / Requested by:
Project Number-Name:
Special Instructions for Analysis or Reporting:
Specimen ID List (or include separate sheet)

Check all applicable tests below. Explain “other” tests in the box above.

RODENT HEALTH SURVEILLANCE

/

CLINICAL PATHOLOGY

/ S155___UCD Hamster Panel
R902___LumX Mouse UCD RHS Level 1 / C010___CBC Hematology / S170___UCD Rabbit Panel
R903___LumX Mouse UCD RHS Level 2 / C015___Manual WBC Differential Exam with slide preparation/staining / L180___LumX JRHS Mouse Quarter
R004___Rat UCD RHS Level 1 / C060___Hemoglobin & Hematocrit / L190___LumX JRHS Mouse Bi-annual
R005___Rat UCD RHS Level 2 / C070___Reticulocyte Count / L200___LumX JRHS Mouse Annual
R006___Guinea pig/Hamster UCD RHS Level 1 / C080___Fluid Analysis Cytology Exam (by Pathologist) / L210___LumX JRHS Mouse Importation
R007___Guinea pig/Hamster UCD RHS Level 2 / C085___Fluid Analysis Cytology Exam (by Clinical Technologist.) / S230___Individual ELISA Test______
R910___LumX JRHS Mouse Quarter Screen / C090___Phenotyping Chem. Panel / S240___2-ELISA Test Panel______
R920___LumX JRHS Mouse Bi-annual Screen / C120___Liver-Kidney Function Chem. Panel / S250___Individual IFA Test______
R930___LumX JRHS Mouse Annual Screen / C130___Small Animal Chem. Panel /

MICROBIOLOGY

R040___JRHS Weanling Screen w/ Micro / C140___Individual Chemistries (please specify) / M010___Aerobic Bacterial Culture

PATHOLOGY

/ C170___Custom Chem (specify 5 tests) / M020___Blood Culture
P010___MouseTier 1 Phenotype Necropsy w/Histology / C180___Custom Chem (specify 10 tests) / M030___Fungal Culture (Derm-Duet only)
P920___LumX UCD Adult Clinical Health Screen / C190___Urinalysis dipstick w/sediment exam / M040___Gram Stains
P030___UCD Weanling Clinical Health Screen / ____Electrolyte Panel (please specify) / M050___Autoclave Test
P940___LumX JAX Adult Clinical Health Screen / ____Lipid Panel (please specify) / M060___RODAC 10-Plate
P050___Jax Weanling Clinical Health Screen /

MOLECULAR DIAGNOSTICS

/ M070___Water Sample
P070___Sm. Animal Gross Necropsy / B010___Helicobacter PCR (1) / M080___Environmental Swab
P080___Sm. Animal Gross w/ Histology / B020___Helicobacter PCR(2-5 pooled) /

PARASITOLOGY

P090___Lg. Animal Gross Necropsy / B040___Pneumocystis carinii PCR / D010___Fecal Floatation
P100___Lg. Animal Gross w/ Histology / B050___Q fever PCR / D060___Fecal Collect/ Intestinal Pinworm
P110___Rodent Gross Necropsy / B060___Mycoplasma sp. PCR / D070___Pelage Collect/Furmite Check
P120___Rodent Gross Necropsy w/Histology / B070___Misc. PCR / D080___Direct Fecal Exam/Smear
P121___Other Sm. Lab Animal Gross Necropsy / B080___Misc. RT-PCR / D090___Pinworm Anal Tape Collection
P122___Other Sm. Lab. Animal Gross Necropsy w/Histology /

SEROLOGY

/ D100___Pinworm Anal Tape Exam
P130___Tissue Collection/Sample______/ L041___LumX UCD Mouse Level 1 Panel / D105___Furmite Pelage Tape Exam
P140___Blood Collect/Serum Processing / L042___LumX UCD Mouse Level 2 Panel /

RESEARCH

P150___Biopsy/Init. Site______/ S061___UCD Rat Level 1 Panel / E001___Slide Interpretation: 1-2 Tissues
P160___Biopsy/ Add. Sites: / S062___UCD Rat Level 2 Panel / E002___Slide Interpretation: Greater than 2
P170___Special Stain w/ Interpretation / L080___LumX UCSF Mouse Level 2 / Other:
P180___Tissue Process w/H & E Slide / S090___UCSF Rat Serology Panel
S155___UCD Guinea Pig Panel

FM-005 08/02/10 Rev. 10