Dd Form 2620 - Request For Laboratory Determination Of Rabies

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REQUEST FOR LABORATORY DETERMINATION OF RABIES
SECTION I - SUBMITTER INFORMATION
1. TO (Laboratory Address)
2.a. FROM (Unit Address, including Country)
b. TELEPHONE (Include Area/Country Code)
(1) DSN
(2) After Hours
(3) Commercial
(4) After Hours
3. SUBMITTING VETERINARIAN
a. NAME (Last, First, Middle Initial)
b. EMAIL
c. DATE (YYYYMMDD)
4. ALTERNATE VETERINARY POINT OF CONTACT
a. NAME (Last, First, Middle Initial)
b. EMAIL
SECTION II - ANIMAL INFORMATION
5. SUBMITTER ASSIGNED SAMPLE ID NUMBER
6. SPECIES AND/OR COMMON NAME (e.g., dog, cat,
7. AGE
skunk, etc.)
(REQUIRED)
Pet
Stray
8. HAS ANIMAL BEEN VACCINATED FOR RABIES?
9.a. DATE ANIMAL WAS VACCINATED
b. TYPE OF VACCINE
(X one)
(YYYYMMDD)
Yes
No
Unknown
10.a. DATE OF DEATH (YYYYMMDD)
11. HUMAN EXPOSURE (X one)
b. MANNER OF DEATH (X one)
Died
Euthanized
Unknown
Yes
No
12. NUMBER EXPOSED (DD Form 2341 (Bite Report) Reference Number, other information. Do NOT include HIPAA related information.)
13. DESCRIPTION (Provide a list of the animal's symptoms and circumstances of exposure. Do NOT include HIPAA related information.)
SECTION III - FOR LABORATORY USE ONLY
14. DATE SAMPLE RECEIVED
15. LABORATORY SAMPLE NUMBER
16. SPECIMEN CONDITION AT RECEIPT
(YYYYMMDD)
17. DFA TEST RESULTS
a. DFA LAB REPORT NUMBER
b. TEST RESULT (X one)
POSITIVE
NEGATIVE
INDETERMINATE
c. DFA RESULT EMAILED TO
d. DATE (YYYYMMDD)
e. TIME
f. INITIALS
18. MNA TEST RESULTS
a. MNA LAB REPORT NUMBER
b. TEST RESULT (X one)
POSITIVE
NEGATIVE
INDETERMINATE
c. MNA RESULT EMAILED TO
d. DATE (YYYYMMDD)
e. TIME
f. INITIALS
DD FORM 2620, AUG 2013
PREVIOUS EDITION IS OBSOLETE.
Adobe Designer 9.0

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