+-----------------------+----------------------------------------------+
| ![](media             | # [INTERIM                                   |
| /image1.jpeg){width=" |  FIELD SPECIMEN COLLECTION FORM]{.underline} |
| 2.1868055555555554in" |                                              |
| height="1             | # [(Animal Form)]                            |
| .5923611111111111in"} | {.underline} [ACCESSIONING FORM]{.underline} |
|                       |                                              |
|                       | ***CDC/NCID/POXVIRUS SECTION***              |
|                       |                                              |
|                       | ***1600 CLIFTON ROAD MS G-18***              |
|                       |                                              |
|                       | ***ATLANTA, GA 30333***                      |
|                       |                                              |
|                       | ## TEL: (404) 639-4931 FAX: (404) 639-3111   |
+-----------------------+----------------------------------------------+

### 

+----------------------------------+-----------------------------------+
| #### **CASE NUMBER**             | **DATE RECEIVED**                 |
|                                  |                                   |
| **(Poxvirus Lab use only):**     | **(Poxvirus Lab use only):**      |
+----------------------------------+-----------------------------------+

Submission instructions must be obtained from the state epidemiologist
([www.cste.org/members/state_and_territorial_epi.asp](http://www.cste.org/members/state_and_territorial_epi.asp))
and state health laboratory
([www.aphl.org/public_health_labs/index.cfm](http://www.aphl.org/public_health_labs/index.cfm))
before sending specimens to CDC.

  ----------------------------------- -----------------------------------
  **STATE OR LOCAL ID NUMBER**        **CDC POX UNIQUE ID NUMBER**

  ----------------------------------- -----------------------------------

+----------------------------------+-----------------------------------+
| **ANIMAL AND OWNER INFORMATION** | **ANIMAL CARE PROVIDER            |
|                                  | INFORMATION (SUBMITTED BY)**      |
+----------------------------------+-----------------------------------+
| Last                             | Last                              |
| Name:\_\_\_\_\_\_\_\_\_\_\_\_\_  | Name:\_\_\_\_\_\_\_\_\_\_\_\_\    |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                  |                                   |
| First                            | First                             |
| Name:\_\_\_\_\_\_\_\_\_\_\_\_\_  | Name:\_\_\_\_\_\_\_\_\_\_\_\_\    |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                  |                                   |
| City:\_\_\_\_                    | Addres                            |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | s:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                  |                                   |
| State:\_\_\_\_\_\_\              | City:\_\_\_                       |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_Zip | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| Code: \_\_\_\_\_\_               | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                  |                                   |
| County:                          | State:\_\_\_\_\                   |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | Zip Code:\_\_\_\_\_\_             |
|                                  |                                   |
| Countr                           | County:                           |
| y:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                  |                                   |
| Animal Common                    | Country:                          |
| Name:\_\_\_                      | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                  |                                   |
| Species (Scientific Name If      | Telephone 1: (\_\_\_\_\_\_)       |
| Known)\_\                        | \_\_\_\_\_\_\_\_-\_\_\_\_\_\_\_\_ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |                                   |
| _:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | Telephone 2: (\_\_\_\_\_\_)       |
|                                  | \_\_\_\_\_\_\_\_-\_\_\_\_\_\_\_\_ |
| Sex: M / F /Unknown              |                                   |
|                                  | Fax: (\_\_\_\_\_\_)               |
| DOB:\_\_\_\_/\_\_\_\_/\_\_\_\_   | \_\_\_\_\_\_\_\_-\_\_\_\_\_\_\_\_ |
| No Info.                         |                                   |
|                                  | Email:                            |
| Additional Animal Descriptor:    | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| \_\_\_\_\_\_\_\_                 | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                                   |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                                   |
|                                  |                                   |
| \_\_\_\_\_\_\_\_                 |                                   |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                                   |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                                   |
+----------------------------------+-----------------------------------+

+-----------------------------------------------------------------------+
| **STATE CONTACT INFORMATION**                                         |
+-----------------------------------------------------------------------+
| Name of State Veterinarian or Primary Contact:                        |
|                                                                       |
| Last Name:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_First                   |
| Name:\_\_\_\_\_\_\_\_\_\_\_\_\                                        |
| _\_\_\_\_\_\_\_Title:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| Email                                                                 |
| Addre                                                                 |
| ss:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| Name of State Epidemiologist or Secondary Contact:                    |
|                                                                       |
| Last Name:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_First                   |
| Name:\_\_\_\_\_\_\_\_\_\_\_\                                          |
| _\_\_\_\_\_\_\_\_Title:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| Email                                                                 |
| Addre                                                                 |
| ss:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| Address:\_\_\_\_\_\_\_\_                                              |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| City:\_\_\_\_\_\_\_\_\_\_\_\_\_                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_State:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Zip |
| Code:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_               |
|                                                                       |
| Telephone 1: (\_\_\_\_\_\_) \_\_\_\_\_\_\_-\_\_\_\_\_\_\_\_ Telephone |
| 2: (\_\_\_\_\_\_) \_\_\_\_\_\_\_-\_\_\_\_\_\_\_\_                     |
|                                                                       |
| Fax: (\_\_\_\_\_\_) \_\_\_\_\_\_\_\_-\_\_\_\_\_\_\_\_                 |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **ANIMAL SOURCE INFORMATION**                                         |
+-----------------------------------------------------------------------+
| Original Animal Source:                                               |
|                                                                       |
| Pet Store Swap Meet Animal Importer Breeder                           |
|                                                                       |
| Other, Specify:                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\     |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| Date of Acquisition: \_\_\_\_/\_\_\_\_/\_\_\_\_                       |
+-----------------------------------------------------------------------+
| **ASSOCIATION WITH A HUMAN CASE**                                     |
+-----------------------------------------------------------------------+
| Animal Associated with a Human Case? Yes No                           |
|                                                                       |
| Was Case Confirmed at the Time of Sample Collection? Yes No           |
|                                                                       |
| Name or Unique Identification Number of                               |
| Case:\_\_\_\_\_\_\_\_\_\_\_\_\                                        |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------------------------------------------+
| **ASSOCIATION WITH OTHER ANIMALS**                                    |
+-----------------------------------------------------------------------+
| Animal Associated with Other Animals, Household Contact or Otherwise? |
| Yes No                                                                |
|                                                                       |
| Species or Common Name of Animal                                      |
| Contact:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                     |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| Duration of                                                           |
| Contact:\_\_\_\_\_\_                                                  |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| Unique Identification Number of Case if                               |
| Known:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                             |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------------------------------------------+
| **ANIMAL HISTORY**                                                    |
+-----------------------------------------------------------------------+
| State of Animal Living Dead Necropsy                                  |
|                                                                       |
| Cause of Death Natural Course Euthanized                              |
|                                                                       |
| Reason for Euthanasia Animal Moribund Study Protocol                  |
|                                                                       |
| Date of Illness Onset \_\_\_\_\_\_/\_\_\_\_/\_\_\_\_\_\_              |
|                                                                       |
| Received Veterinary Care? Yes No                                      |
|                                                                       |
| Outcome? Recovered Died Date of Death:                                |
| \_\_\_\_\_\_/\_\_\_\_/\_\_\_\_\_\_                                    |
|                                                                       |
| [Symptoms]{.underline}: (Check all that apply)                        |
|                                                                       |
| Conjunctivitis Upper Respiratory Tract Infection Weight Loss Hair     |
| Loss                                                                  |
|                                                                       |
| Loss of Appetite Decrease in Normal Activity                          |
|                                                                       |
| Lesions: Yes No Rash Onset Date:\_\_\_\_\_\_/\_\_\_\_/\_\_\_\_\_\_    |
|                                                                       |
| [Lesion Type]{.underline}: (Check all that apply)                     |
|                                                                       |
| Macules Approx                                                        |
| No:\_\_\_\_\_\_\_\_Location:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_            |
|                                                                       |
| Papules Approx                                                        |
| No:\_\_\_\_\_\_\_\_Location:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_            |
|                                                                       |
| Vesicles Approx                                                       |
| No:\_\_\_\_\_\_\_\_Location:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_            |
|                                                                       |
| Pustules Approx                                                       |
| No:\_\_\_\_\_\_\_\_Location:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_            |
|                                                                       |
| Other\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\              |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_(and |
| see text box below)                                                   |
+-----------------------------------------------------------------------+

  -----------------------------------------------------------------------
  **ANIMAL HISTORY AND OBSERVATIONS**

  -----------------------------------------------------------------------

Only two specimens from the same animal can be reported on this page.
Please print as many pages as needed (one page for every two specimens
submitted).

+-----------------------------------------------------------------------+
| **CDC POXLAB CASE NUMBER: 2003-\_\_\_\_\_\_\_\_\_\_**                 |
|                                                                       |
| **STATE OF ANIMAL** **AT COLLECTION**: Living (Well) Living (Ill)     |
| Necropsy                                                              |
+-----------------------------------------------------------------------+
| Date Collected:\_\_\_\_\_\_\_\_/\_\_\_\_\_\_\_\_/\_\_\_\_\_\_\_\_     |
| DASH Number:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                            |
|                                                                       |
| **SAMPLE MATERIAL** (Circle)                                          |
|                                                                       |
|   ------------------------ ------------------------ ----------------  |
|   Vesicle Skin             Serum                    Lung              |
|                                                                       |
|   Vesicle Swab             Oral Swab                Heart             |
|                                                                       |
|   Vesicle Fluid            Formalin-Fixed Tissue    Eyelid            |
|                                                                       |
|   Vesicle Skin             Gonad                    Tongue            |
|                                                                       |
|   Pustule Skin             Feces                    Brain             |
|                                                                       |
|   Pustule Fluid            Lymph Node               Ocular Swab       |
|                                                                       |
|   Crust                    Urine                    Tissue, Pooled    |
|                                                                       |
|   Oropharyngeal Tissue     Kidney                   Liver             |
|                                                                       |
|   CSF                      Spleen                   Blood             |
|                                                                       |
|   Lesion                   Skin                                       |
|                                                                       |
|   Other, Specify:                                                     |
|   ------------------------ ------------------------ ----------------  |
|                                                                       |
| **COLLECTION METHOD** (Circle)                                        |
|                                                                       |
|   ------ ------- ----------- ------ ---------                         |
|  ---------- --------------------------------------------------------- |
|   Swab   Slide   Container   EM     Syringe   Biopsy /   Other,       |
|                              Grid                                     |
|    Formalin   Specify\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
|   ------ ------- ----------- ------ ---------                         |
|  ---------- --------------------------------------------------------- |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **STATE OF ANIMAL AT COLLECTION:** Living (Well) Living (Ill)         |
| Necropsy                                                              |
+-----------------------------------------------------------------------+
| Date Collected:\_\_\_\_\_\_\_\_/\_\_\_\_\_\_\_\_/\_\_\_\_\_\_\_\_     |
| DASH Number:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                            |
|                                                                       |
| **SAMPLE MATERIAL** (Circle)                                          |
|                                                                       |
|   ------------------------ ------------------------- ---------------- |
|   Vesicle Skin             Serum                     Lung             |
|                                                                       |
|   Vesicle Swab             Oral Swab                 Heart            |
|                                                                       |
|   Vesicle Fluid            Formalin-Fixed Tissue     Eyelid           |
|                                                                       |
|   Vesicle Skin             Gonad                     Tongue           |
|                                                                       |
|   Pustule Skin             Feces                     Brain            |
|                                                                       |
|   Pustule Fluid            Lymph Node                Ocular Swab      |
|                                                                       |
|   Crust                    Urine                     Tissue Pooled    |
|                                                                       |
|   Oropharyngeal Tissue     Kidney                    Liver            |
|                                                                       |
|   CSF                      Spleen                    Blood            |
|                                                                       |
|   Lesion                   Skin                                       |
|                                                                       |
|   Other, Specify:                                                     |
|   ------------------------ ------------------------- ---------------- |
|                                                                       |
| **COLLECTION METHOD** (Circle)                                        |
|                                                                       |
|   ------ ------- ----------- ------ ---------                         |
|  ---------- --------------------------------------------------------- |
|   Swab   Slide   Container   EM     Syringe   Biopsy /   Other,       |
|                              Grid                                     |
|    Formalin   Specify\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
|   ------ ------- ----------- ------ ---------                         |
|  ---------- --------------------------------------------------------- |
+-----------------------------------------------------------------------+