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pdf** NO SPECIMENS ACCEPTED WITHOUT PRIOR CONSULTATION **
Call (404) 639-1510 or (404) 639-1115 for authorization to ship specimens.
Instructions for completing the Ebola Diagnostic Specimen Submission Form for quarantined non-human primate materials
• Send specimens by overnight courier (Federal Express preferred). Fax the Tracking Number and packing list to VSPB at (404) 639-1509 or
(404) 639-1118.
• Package in accordance with the International Air Transport Association and US Department of Transportation regulations to prevent leakage.
(See https://www.iata.org/publications/dgr/Pages/manuals.aspx and http://www.hercenter.org/regsandstandards/Transporting_Infectious_Substances_Safely.pdf)
• Label shipment as Diagnostic Specimen and include the following information: test(s) requested, date of collection, laboratory or accession number, the type of specimen being shipped, and this Specimen Submission Form.
• On the outside of the box, specify how the specimen should be stored: Refrigerated, Frozen, or Do Not Refrigerate.
• A payment of $540 US is due upon completion of testing. CDC accepts Visa and Mastercard. Please provide billing information on next page.
For Ebola antigen detection:
• Requires fresh-frozen tissues collected during
necropsy
• Be sure to adhere to the Biosafety and Personal
Protective equipment requirement when collecting
and packaging specimens.
• Tissues required: liver (Spleen can be added but is
not required.)
• Collect 2 pieces of at least 1cm3 each, and put them
in two separate plastic tubes, correctly labeled.
Tube caps should be tight to avoid leakage during
manipulation and transportation.
• Put each tube in zip-locked or heat-sealed bag.
• Tissues must be shipped on dry ice or frozen cold
pack.
• The accompanying documentation should be
in another zip-locked (or sealed) bag to avoid
contamination in case of leakage.
PAYMENT INFORMATION
Payments can be made at PAY.GOV or by
check. Upon submission of this form, an
electronic invoice is generated by CDC, and
sent to the email address of the sender. (Be
sure to send us the completed form from a
monitored email address.) Instructions for
payment by credit card or by check are included in the electronic invoice document.
Note that while samples will be tested as
soon as they are received, test results are
not released until payment is received.
HOW TO SEND THIS COMPLETED FORM TO CDC
BY SURFACE MAIL:
print this Form and send to:
Centers for Disease Control and Prevention
1600 Clifton Rd. NE
Viral Special Pathogens Branch
Bldg. 15, MS G-14
Atlanta, GA USA 30329
BY EMAIL:
Hit the ‘Send to CDC’ button at the bottom right of page
2. Your computer will generate an email containing the
completed information. Hit the ‘Send’ button in your email
application to send the email to CDC. Acknowledgement of
receipt is not provided.
BY FAX:
print this Form and fax to:
(404) 639-1509, or
(404) 639-1118
** NO SPECIMENS ACCEPTED WITHOUT PRIOR CONSULTATION **
Call (404) 639-1510 or (404) 639-1115 for authorization to ship specimens.
OMB No. 0920-0263
Exp. 04/30/2016
Viral Special Pathogens Branch, CDC
Ebola Diagnostic Specimen Submission Form for quarantined non-human primates
Please return to: Centers for Disease Control and Prevention, Viral Special Pathogens Branch
Ph: (404) 639-1510 Fax: (404) 639-1118 Email: [email protected]; [email protected]
Site: http://www.cdc.gov/ncidod/dvrd/spb/mnpages/specimen.htm
BEFORE SHIPPING
REQUIRED LABELING
• Prior consultation with VSPB staff is
required before specimens will be
tested. Please call (404) 639-1115 or
(404) 639-1510 for assistance.
• Please include a copy of this Form with
the specimen shipment, and fax or
email a copy using the “Send to CDC”
button below.
• Shipments should be labeled as
Diagnostic Specimens
• Name and contact info of shipment
preparer
• Name and contact info for who
should receive test results
• On tubes: date of collection and tatoo/
ID number
ANIMAL INFORMATION
Species:
Choose one
• Overnight shipping is preferred.
• Please send an email with the shipping
number to [email protected]
• On outside of box, specify how specimen
should be stored: refrigerated, frozen.
Age:
Choose one
Centers for Disease Control and Prevention
ATTN STAT LAB: VSPB, Unit #70
1600 Clifton Road NE
Atlanta, GA 30333
Phone: (404) 639-1115 (VSPB Lab) or
(404) 639-1118 (VSPB fax)
Package in accordance with IATA regulations to
prevent leakage. See: http://emergency.cdc.gov/
labissues/#shipping
SHIPMENT INFORMATION
Your quarantine facility: Choose one
Animal tatoo #:
Contact person:
Date of arrival at quarantine facility:
Email results to:
Country of origin, if known:
Email results to:
Number of NHP in shipment:
Shipper:
Died:
SHIPPING
Other:
Other:
Sex:
HANDLING
Euthanized:
Other information:
Date:
Choose one
Phone:
AWB#:
Other:
Date of shipping:
SPECIMEN INFORMATION
Date of specimen collection:
Type of specimen:
Other:
Specimen number:
Packaging:
Choose one
ADDITIONAL INFORMATION
Instructions: You must have internet access and an email address to submit this Form electronically. Upon hitting the ‘Submit by email’ button, a PDF is created, attached to an
email, which you should then send to the addresses which appear in the address header; you may also cc: others. Acknowledgement of receipt by CDC is not provided.
Submit by
Email
SUBMIT
TO
CDC
Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person
is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any
other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74,
Atlanta, Georgia 30333; ATTN: PRA 0920-0263.
| File Type | application/pdf |
| File Modified | 2014-01-14 |
| File Created | 2013-05-16 |