Wageningen Bioveterinary Research, P.O. Box 65, 8200 AB Lelystad, + 31 (0) 320 238302; ;
www.wur.eu/bioveterinary-research. Authorization number Animal By-product Regulation: CVI 35998

For Wageningen Bioveterinary Research use only:

Uitpakken / Registratie / Controle registratie / Opdrachtnummer

Submission form Horses

þ Results in English

Please fill in the form as completely as possible!

(For acceptance policy, see our website)

Sender: / Exporter:
Client number # / Debit number #
Name* / Name
Address* / Address
Postal code* / Postal code
City* / City
Country* / Country
Email address

- The invoice will be sent to sender

Owner: / Animal species*:
Name* / Horse
Address* / Other,
Postal code*
City*
Country*
Your reference code:
(This code will be reproduced on the test results report and on the invoice, max. 20 characters)
Reason for testing*:
Import / Export country
Export / Import country
Screening / Export date
Other, please specify
Sending date* / Sampling date*
Filled in by (name)* / Signature*
Remarks: / VAT number:

Sample ID submission form Horse

(Please use one sample ID form per sample type)

Sample type*:
Blood (serum) / Blood (heparin) / Blood (EDTA)
Faeces / Semen / Organ / (number of) swabs
Other, please specify:

Required serological tests:

APP01 / Afrikaanse Paardepest (African Horse Sickness) serology / EHV01 / Equine Herpes Virus serology (paired sera only)
BAS01 / Brucella abortus serology CBR / 1st date sample; 2nd date sample
BAS03 / Brucella abortus serology SAT / LCA01 / Leptospira canicola MAT
BCB01 / Babesia Caballi (Piroplasmosis) IFT / LHA01 / Leptospira hardjo serology
BCB03 / Babesia Caballi (Piroplasmosis) CBR / SAE01 / Salmonella abortus equi serology
BCB04 / Babesia Caballi (Piroplasmosis) cElisa / TEQ01 / Tryp. Equiperdum (Dourine) serology
BUM01 / Burkholderia mallei serology (Malleus) / TEV01 / Trypanosoma evansi CATT
EAV01 / Equine Arteritis Virus serology / THE01 / Theileria equi (piroplasmosis) IFT
EAV03 / Equine Arteritis Virus serology (titer) / THE03 / Theileria equi (piroplasmosis) CBR
EEV01 / Equine Encephalom. virus (WEE, EEE, VEE) / THE04 / Theileria equi (piroplasmosis) cElisa
EIA01 / Equine Infectectious Anaemia Virus serology AGIDT (Coggins) / VSV01 / Vesicular stomatitis virus serology
EIA03 / Equine Infectectious Anaemia virus Elisa / WNV01 / West nile virus serology
For other tests please consult our Tarievenlijst on the website

Sample ID

1 / 6 / 11
2 / 7 / 12
3 / 8 / 13
4 / 9 / 14
5 / 10 / 15

Required non serological tests:

CEM02 / T. equigenitalis (CEM) isolation / EHV02 / Equine Herpes Virus PCR ( Swab)
CEM05 / T. equigenitalis (CEM) PCR / INF03 / Equine influenza (pool)
EAV02 / Equine Arteritis Virus virus isolation / TEV02 / Trypanosoma evansi parasitological (Smear)
EAV04 / Equine Arteritis Virus PCR
EPI02 / Equine piroplasmose smear
For other tests please consult our Tarievenlijst on the website

Sample ID

1 / 6 / 11
2 / 7 / 12
3 / 8 / 13
4 / 9 / 14
5 / 10 / 15
Date* / Signature*

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* Obligatory field

# You can ask division DSU +31 (0) 320 238302, or mail to Form I English, version Sept. 2016

N.B. Possible deflections on the results have to be mentioned within two weeks after receiving the results