Ebola Diagnostic Specimen Submission Form for quarantine

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** NO SPECIMENS ACCEPTED WITHOUT PRIOR CONSULTATION **
Call 470-312-0094 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) 471-2526.
You may also email this information to: [email protected]
• Package in accordance with the International Air Transport Association and US Department of Transportation regulations to prevent leakage.
(See http://www.iata.org/publications/dgr/Pages/index.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 requirements when collecting
and packaging specimens.
• Tissues required: liver (Spleen can be added but is
not required.)

PAYMENT INFORMATION

• Collect two 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 a 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.

Put form into
sealable plastic bag

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
ATTN STAT LAB: VSPB, Unit #70,
1600 Clifton Rd. NE, Atlanta, GA. 30333
Phone: (470) 312-0094

BY EMAIL:
Send this form to [email protected].

BY FAX:
print this Form and fax to:
(404) 471-2526

** NO SPECIMENS ACCEPTED WITHOUT PRIOR CONSULTATION **
Call 470-312-0094 for authorization to ship specimens.

Reset Form
OMB No. 0920-0263
Exp. 8/31/2020

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: (470) 312-0094 or Fax: (404) 471-2526 Email: [email protected]; [email protected]
Site: https://www.cdc.gov/ncezid/dhcpp/vspb/specimens.html
BEFORE SHIPPING

REQUIRED LABELING

• Prior consultation with VSPB staff is
required before specimens will be
tested. Please call 470-312-0094 or
email [email protected] for assistance.
• Please include a copy of this Form
with the specimen shipment, and fax
or email a copy to [email protected].

• 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

HANDLING

SHIPPING

• 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.

Centers for Disease Control and Prevention
ATTN STAT LAB: VSPB, Unit #70
1600 Clifton Road NE
Atlanta, GA 30333
Phone: (470) 312-0094 or (404) 471-2526
Package in accordance with IATA regulations
to prevent leakage. See: http://emergency.
cdc.gov/labissues/#shipping

ANIMAL INFORMATION

SHIPMENT INFORMATION

Species:

Your quarantine facility:

Other:

Other:
Age:

Sex:

Animal tattoo #:

Contact person:

Date of arrival at quarantine facility:

Email results to:

Country of origin, if known:

Email results:

Number of NHP in shipment:

Shipper:

Died:

Euthanized:

Date:

Phone:

AWB#:

Other:
Date of shipping:

Other information:

SPECIMEN INFORMATION
Date of specimen collection:
Type of specimen:
Other:
Specimen number:
Packaging:

ADDITIONAL INFORMATION

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.
CS287667

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