Fillable Split Sample Submission Form LSU Equine Medication Surveillance Laboratory (EMSL)

Fill Online, Printable, Fillable, Blank Split Sample Submission Form LSU Equine Medication Surveillance Laboratory (EMSL) Form

Use Fill to complete blank online LOUISIANA STATE UNIVERSITY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Split Sample Submission Form LSU Equine Medication Surveillance Laboratory (EMSL)

On average this form takes 9 minutes to complete

The Split Sample Submission Form LSU Equine Medication Surveillance Laboratory (EMSL) form is 3 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 36 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Louisiana State University

BROWSE LOUISIANA STATE UNIVERSITY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
LSU Equine Medication
Surveillance Laboratory
SPLIT SAMPLE ANALYSIS REQUEST
SPLIT SAMPLE ANALYSIS REQUEST
LSU Equine Medication Surveillance Laboratory (EMSL)
LSU School of Veterinary Medicine
River Road, LADDL 2054
Baton Rouge, LA 70803
Office Phone: 225-578-3601
Fax: 225-578-9555
Please fax this split sample analysis request form prior to sending the sample. Laboratory confirmation
of acceptance will follow and the sample may then be shipped. Samples must be shipped in a manner
that insures adequate chain of custody. Thus the information provided with the sample should include
sample number, intact seals properly initialed and dated and shipping documents. Urine samples should
be shipped frozen in an insulated container with ice packs to insure temperature control. Blood samples
should be centrifuged and serum or plasma separated from red cells or in serum separator tubes and sent
frozen. Blood samples not separated should be shipped cold in an insulated container with icepacks.
The amount of sample required is generally 5mls for urine samples and 2mls for plasma samples. All
samples are done in duplicate and it is preferable to have enough sample for a repeat assay should it
become necessary. Any questions as to the amount should be directed to the Director of the EMSL
before submitting the sample for analysis.
Payment should be included with the sample at the time of shipment if this procedure is in keeping with
jurisdiction practice otherwise payment must be received before analysis and release of data.
Arrangements for invoicing payment must be made through the Director of the EMSL and is only
offered to institutions and not to individuals.
Levent Dirikolu, DVM, MVSc, PhD
Professor of Pharmacology
Director, Equine Medication Surveillance Laboratory
Department of Comparative Biomedical Sciences
School of Veterinary Medicine
Louisiana State University
Skip Bertman Drive
Baton Rouge, LA 70803
Office: 225-578-9885
Email: ldirikolu@lsu.edu
LSU Equine Medication
Surveillance Laboratory
SPLIT SAMPLE ANALYSIS REQUEST
SPLIT SAMPLE ANALYSIS REQUEST
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
___________________________________________________
Laboratory Reporting Positive____________________________________________
Contact info for Laboratory_______________________________________________
Please check:
Sample Type(s) Urine ________ Whole Blood________ Plasma ________Serum______
Sample Volume (ml) Urine ________ Whole Blood________ Plasma ________Serum______
Sample ID Number: Urine_____________________ Blood_____________________
Drug and/or Drug Metabolite Reported:
Urine_________________________________________________________________
Blood_________________________________________________________________
Approximate Concentration: (if known)
Urine_________________________________________________________________
Blood_________________________________________________________________
Qualitative Analysis ONLY Requested: yes__________ no__________
Quantification Requested: yes __________ no__________
Money Order Included: yes__________ no__________
Submitting Agency:
Address/ Phone /
Fax/e-mail
LSU Equine Medication
Surveillance Laboratory
SPLIT SAMPLE ANALYSIS REQUEST
SPLIT SAMPLE ANALYSIS REQUEST
Anticipated Shipping Date: _______________________________________________
Shipping Method: _______________________________________________________
Tracking Number: ______________________________________________________
***We do not pay for return shipping for sample containers. Containers that require return must
be accompanied by return shipping form (FedEx or UPS); and a label showing the return address
and phone number:
Shipping Container Return Address & Phone Number:
_______________________________________________________________________
_______________________________________________________________________
Contact Information-Person to whom results should be reported:
Name: _________________________________________________________________
Phone: _________________________________________________________________
Fax: _________________________________________________________________
E-mail: _________________________________________________________________
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Split Sample Submission Form LSU Equine Medication Surveillance Laboratory (EMSL)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 19 June 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document