Division of Laboratory Animal Medicine
Hematology Request Form
Requests should be submitted at least two days before submission date. At least 75ul of EDTA
preserved blood is recommended for each sample. Samples should be collected and
submitted the same day. A separate submission form for each species and strain is required.
Please be sure to type or print clearly.
Each CBC is $13.00 and will be charged to the provided account at the end of the month. If 20
or more samples of the same strain are submitted on the same day by the same PI, a discount
of $1 will be applied to each sample.
Contact Andrea Willis by phone at 5-8599 or email at awillis42@siumed.edu if you have any
questions.
Lab Personnel: Fill out entire form and attach in an email to your fiscal officer.
Fiscal Officer: Please add AIS account number, approve charges, and forward to
ResearchCores@siumed.edu.
Hematology Submission Form
Name
Principle Investigator
Species
Strain
Number of Sample(s)
Protocol #
Lab Room #
Phone #
Requested Submission
Date
Requested Submission
Time
AIS Account #
Page 1
Sample ID
Age
Sex
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Page 2
Additional
Information