Fillable Dd Form 2834 - Veterinary Consultation Request (Page 2 of 2) in pdf

IMPORTANT

Have you enclosed a legible summary of the clinical findings, laboratory data, operative findings or report, and

specific treatment? Have you included a copy of the original pathology or autopsy report? Cases selected for

inclusion in specific registries often require additional information. Clinical or gross photos, pertinent X-rays, and

additional diagnostic materials add substantially to the educational value of the case and are highly desired.

AFIP RETENTION POLICY

- Microscopic slides are kept on permanent file.

- Blocks are retained for a minimum of five years, unless return is requested at the time a case is accessioned.

- Blocks on cases judged to have educational or research value may be retained indefinitely.

- Other material may be discarded when no longer used for education or research.

- Further information can be obtained from the AFIP Contributors Manual available from the AFIP Research

Office at (202) 782-2500.

- WEBSITE:

PRIVACY ACT STATEMENT

AUTHORITY: 5 USC 301 and 44 USC 3014.

PRINCIPAL PURPOSE(S): Medical information received is considered during the consultative process and is used

to form a database for education and research in pathology. Other patient information is used for filing and

retrieval of consultation records. Information concerning the contributor is used to maintain contributor mailing

lists.

ROUTINE USE(S):

a. Pathology consultation files are used to provide a database for medical research and statistical purposes,

and when required by law or for other official purposes, individual records may be released to the referring

medical care provider (physician, veterinarian), to medical care providers treating the individual, to qualified

medical researchers and students, and to other Federal agencies and law enforcement personnel when requested

for official purposes involving criminal prosecution, civil court action or regulatory orders.

b. Pathology contributor mailing lists/files are used to publicize changes in policies and procedures pertaining

to requests for consultative services and to disseminate information pertaining to continuing medical education

courses or educational materials available at the AFIP.

DISCLOSURE: Voluntary; however, if the information is not furnished, consultation may not be possible and

material submitted may be returned without review.

Please send all submitted material together. Address the material to:

Armed Forces Institute of Pathology

ATTN: Receiving and Accessions Division (AFIP-RRS)

Room G-071, Building #54

6825 16th Street, N.W.

Washington, DC 20306-6000

Telephone No. (202) 782-1630

Fax No. (202) 782-7845

The form can be printed from DefenseLINK, under Publications.

If a civilian contractor (non-Federal), I certify to the best of my knowledge and belief that no litigation or claim of

professional negligence involving the medical care of this patient has been or is about to be filed. ALL

CONTRIBUTORS by their signature affirm that they have read the PRIVACY ACT STATEMENT above.

19. SIGNATURE OF CONTRIBUTOR

20. DATE REQUEST FORWARDED

(YYYMMMDDD)

DD FORM 2834 (BACK), SEP 2002

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Dd Form 2834 - Veterinary Consultation Request Page 2

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