P.O. Box 65, 8200 AB Lelystad, + 31 (0) 320 238302; www.wageningenur.nl/en/cvi; dsu.cvi@wur.nl
Authorization number Animal By-product Regulation: CVI 35998
For CVI use only:
Uitpakken
Registratie
Controle
registratie
Submission form Horses
Opdrachtnummer
 Results in English
Please fill in the form as completely as possible!
(For acceptance policy, see our website: web: www.wageningenur.nl/cvi)
Sender:
Client number (if known) #
Name*
Address*
Postal code*
City*
Country*
Email address
- The invoice will be sent to sender
Exporter:
Debit number
Name
Address
Postal code
City
Country
Owner:
Name*
Address*
Postal code*
City*
Country*
#
Animal species*:
Horse
Other,
Your reference code*:
(This code will be reproduced on the test results report and on the invoice, max. 20 characters)
Reason for testing*:
Import
Export
Screening
Export country
Import country
Export date
Other, please specify
Sending date*
Filled in by (name)*
Remarks:
Sampling date*
Signature*
VAT number:
Page 1 of 2
*
Obligatory field
You can ask division DSU +31 (0) 320 238302
Form I English, version November 2015
N.B. Possible deflections on the results have to be mentioned within two weeks after receiving the results
#
P.O. Box 65, 8200 AB Lelystad, + 31 (0) 320 238302; www.wageningenur.nl/en/cvi; dsu.cvi@wur.nl
Authorization number Animal By-product Regulation: CVI 35998
Page 2 of 2
*
Obligatory field
You can ask division DSU +31 (0) 320 238302
Form I English, version November 2015
N.B. Possible deflections on the results have to be mentioned within two weeks after receiving the results
#
P.O. Box 65, 8200 AB Lelystad, + 31 (0) 320 238302; www.wageningenur.nl/en/cvi; dsu.cvi@wur.nl
Authorization number Animal By-product Regulation: CVI 35998
Your reference code*:
Sample ID submission form Horse
(Please use one sample ID form per sample type)
Sample type*:
Blood (serum)
Faeces
Other, please specify:
Blood (heparin)
Semen
Required serological tests:
APP01
BAS01
BAS03
BCB01
BCB03
BCB04
BUM01
EAV01
EAV03
EEV01
EIA01
EIA03
African horse sickness
Blood (EDTA)
Organ
EHV01
Equine Herpes Virus serology (only two sets of sera)
1st date sample;
2nd date sample
LCA01
LHA01
SAE01
Leptospira canicola MAT
Leptospira hardjo serology
Salmonella abortus equi serology
1st date sample;
2nd date sample
Tryp. Equiperdum (Dourine) serology
Trypanosoma evansi CATT
Theileria equi (piroplasmosis) IFT
Brucella abortus serology CBR
Brucella abortus serology SAT
Babesia Caballi (Piroplasmosis) IFT
Babesia Caballi (Piroplasmosis) CBR
Babesia Caballi (Piroplasmosis) cElisa
Burkholderia mallei serology (Malleus)
Equine Arthritis Virus serology
Equine Arthritis Virus serology (titer)
Equine Encephalom. virus (WEE, EEE, VEE)
Equine Infectious Anemia virus serology AGIDT (Coggins)
Equine Infectious Anemia virus Elisa
(number of) swabs
TEQ01
TEV01
THE01
THE03
THE04
VSV01
WNV01
Theileria equi (piroplasmosis) CBR
Theileria equi (piroplasmosis) cElisa
Vesicular stomatitis virus serology
West Nile virus serology
For other tests please consult our Tarievenlijst on the website
Sample ID
1
6
11
2
7
12
3
8
13
4
9
14
5
10
15
Required non serological tests:
CEM02
EAV02
EAV04
EHV02
TEV02
INF03
T. equigenitalis (CEM) isolation
Equine Arthritis Virus virus isolation
Equine Arthritis Virus PCR
Equine Herpes Virus PCR ( Swab)
Trypanosoma evansi parasitological (Smear)
Equine influenza (pool)
For other tests please consult our Tarievenlijst on the website
Sample ID
1
6
11
2
7
12
3
8
13
4
9
14
5
10
15
Date*
Signature*
Page 3 of 2
*
Obligatory field
You can ask division DSU +31 (0) 320 238302
Form I English, version November 2015
N.B. Possible deflections on the results have to be mentioned within two weeks after receiving the results
#