**National Institutes of Health,**

> **Institute Name Here**

**Bethesda, Maryland, U.S.A.**

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<tbody>
<tr class="odd">
<td colspan="37"><h1 id="animal-health-data-request-template">ANIMAL
HEALTH DATA REQUEST TEMPLATE</h1></td>
</tr>
<tr class="even">
<td colspan="37"><h1
id="nih-policy-requires-rodents-to-be-free-of-lymphocytic-choriomeningitis-virus-mouse-poxvirus-and-hantavirus.">NIH
policy requires rodents to be free of lymphocytic choriomeningitis
virus, mouse poxvirus, and hantavirus.</h1></td>
</tr>
<tr class="odd">
<td colspan="9"><strong><u>ORIGINATING FACILITY:</u></strong></td>
<td colspan="28">     </td>
</tr>
<tr class="even">
<td colspan="9"><strong>Originating Institution:</strong></td>
<td colspan="28">     </td>
</tr>
<tr class="odd">
<td colspan="8"><strong>Investigator Last Name:</strong></td>
<td colspan="16">     </td>
<td colspan="5"><strong>First:</strong></td>
<td colspan="8">     </td>
</tr>
<tr class="even">
<td colspan="2"><strong>E-mail:</strong></td>
<td colspan="16">     </td>
<td colspan="5"></td>
<td colspan="14"></td>
</tr>
<tr class="odd">
<td colspan="2"><strong>Vivarium:</strong></td>
<td colspan="16">     </td>
<td colspan="13"><strong>Vivarium Room:</strong></td>
<td colspan="5">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="10"><strong>Veterinarian’s Last Name</strong></td>
<td colspan="11">     </td>
<td colspan="4"><strong>First:</strong></td>
<td colspan="12">     </td>
</tr>
<tr class="odd">
<td colspan="3"><strong>Vet Voice</strong>:</td>
<td colspan="18">     </td>
<td colspan="4"><strong>Fax:</strong></td>
<td colspan="12">     </td>
</tr>
<tr class="even">
<td colspan="3"><strong>Vet E-Mail</strong>:</td>
<td colspan="12">     </td>
<td colspan="15"><strong>Additional Contact(s)?:</strong></td>
<td colspan="7">     </td>
</tr>
<tr class="odd">
<td colspan="37"></td>
</tr>
<tr class="even">
<td colspan="37"><strong><u>COLONY DESCRIPTION:</u></strong></td>
</tr>
<tr class="odd">
<td colspan="17"><strong>Approximate Colony: Size In Room?:
<u>     </u></strong></td>
<td colspan="9"><strong>Immune Status:</strong></td>
<td colspan="7"><strong>Normal</strong></td>
<td colspan="2"><strong>Deficient</strong></td>
<td colspan="2"><strong>Undetermined</strong></td>
</tr>
<tr class="even">
<td colspan="7"><strong>Breeding In Room?:</strong></td>
<td colspan="7"><strong>YES</strong></td>
<td colspan="19"><strong>NO</strong></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="4"><strong>Colony Status</strong></td>
<td colspan="8"> <strong>CLOSED</strong></td>
<td colspan="21"> <strong>OPEN w/ Quarantine Required</strong></td>
<td colspan="2"><strong>OPEN</strong> </td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="22"><strong>Do Incoming Animals Come from Multiple
Sources?:</strong></td>
<td colspan="6"><strong>YES</strong></td>
<td colspan="5"><strong>NO</strong></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="37"><strong><u>SENTINEL PROGRAM:</u></strong></td>
</tr>
<tr class="even">
<td colspan="37"><strong>(Please attach a letter explaining your
sentinel program &amp; known positives, or complete this section &amp;
provide a copy of the latest sentinel test results.)</strong></td>
</tr>
<tr class="odd">
<td colspan="13"><strong># Sentinel Boxes In Room:
<u>     </u></strong></td>
<td colspan="6"><strong>Animals tested :</strong></td>
<td colspan="13"><strong>Retired breeders</strong></td>
<td colspan="3"><strong>Sentinels</strong></td>
<td colspan="2"><strong>Experimental</strong></td>
</tr>
<tr class="even">
<td colspan="11"><strong>Frequency of Monitoring?:</strong></td>
<td colspan="5"> <strong>Quarterly</strong></td>
<td colspan="11"> <strong>Semi-Annually</strong></td>
<td colspan="7"> <strong>Annually</strong></td>
<td colspan="3"> <strong>Other<u>     </u></strong></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>Sentinel on Dirty Bedding</strong></td>
<td colspan="5"> <strong>YES</strong></td>
<td colspan="4"> <strong>NO</strong></td>
<td colspan="17"><strong>(</strong> <strong>Other method of sentinel
exposure       )</strong></td>
</tr>
<tr class="even">
<td colspan="37"><strong>Any Pathogens or Other Health Problems In Room
in Previous Year?: <u>     </u></strong></td>
</tr>
<tr class="odd">
<td colspan="37"><p><strong>Please List Pathogens or Potential Pathogens
Present in other Rodent Rooms in Same Vivaria:</strong> <strong>None
Present</strong></p>
<p><strong>     </strong></p></td>
</tr>
<tr class="even">
<td colspan="37"><strong><u>HUSBANDRY:</u></strong></td>
</tr>
<tr class="odd">
<td colspan="37"><strong>Is Husbandry Shared With Any Rooms that Contain
Potential Rodent Pathogens?:</strong> <strong>NO</strong>
<strong>YES</strong></td>
</tr>
<tr class="even">
<td colspan="5"><strong>If Yes, List Organisms</strong></td>
<td colspan="32"><strong><u>     </u></strong></td>
</tr>
<tr class="odd">
<td colspan="6"><strong>Caging System:</strong></td>
<td colspan="10"><strong>Conventional</strong></td>
<td colspan="11"><strong>Microisolator</strong></td>
<td colspan="8"><strong>Flow through</strong></td>
<td colspan="2"><strong>Other <u>     </u></strong></td>
</tr>
<tr class="even">
<td colspan="6"><strong>Protective Equipment:</strong></td>
<td colspan="10"><strong>Gloves</strong></td>
<td colspan="11"><strong>Shoe covers</strong></td>
<td colspan="8"><strong>Hair covers</strong></td>
<td colspan="2"><strong>Masks</strong></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="5"></td>
<td colspan="10"><strong>Dedicated clothing</strong></td>
<td colspan="11"><strong>Disposable clothing</strong></td>
<td colspan="8"><strong>Change hoods</strong></td>
<td colspan="2"><strong>Shower-in</strong></td>
</tr>
<tr class="even">
<td colspan="37"><strong><u>TESTING BIOLOGICALS:</u></strong></td>
</tr>
<tr class="odd">
<td colspan="37"><strong>Are biologicals for use in animals routinely
tested before use in your facility?:</strong> <strong>NO</strong>
<strong>YES</strong> <strong>Unknown</strong></td>
</tr>
</tbody>
</table>

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  **Veterinarian:**   **     **                                                                                                          **[     ]{.underline}**             

                                  **^(Print\ name)^**                    **^(Signature)^**                                               **^(Date)^**                        

  **Please Fax the                                      **     **                                        **at**   **     **                                                  
  completed form to**                                                                                                                                                        

  **Questions?                                                                               **     **                        **or                                 **(301)   
  Contact the Import                                                                                                          phone:**                                  **   
  Coordinator:                                                                                                                                                               
  E-mail:**                                                                                                                                                                  

  **     **                                                                                                                                                                  
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