This form is to be filled by the sending institute veterinarian. Sending Institute Information Name and address of Institution from which animals are to be obtained * Institutional Veterinarian Name: * Phone: * Email: * Specific Animal Facility Description Animal Facility * Caging system Individually Ventilated Filter-top cages Conventional (open-top) Other Specify Other: * Use of decontaminated: Food * Yes No Water * Yes No Bedding * Yes No Protective measures for staff: * Mask Gloves Shoe Covers Disposable Clothing Change Hoods Shower-In Do incoming animals come from multiple sources? * Yes No Do you receive rodents from non commercial vendors? * Yes No Are non-vendor rodents introduced into the facility without prior screening? * Yes No Can rodents be returned to room after removal from the animal facility ? * Yes No To which Animal Biosafety Level (ABSL) belong the mice you will send? * ABSL-1 ABSL-2 ABSL-3 Breeding in room? * Yes No Health monitoring program Is There a health monitoring program at your facility? * Yes No Sentinels on dirty bedding? * Yes No Please give details * Diagnostic tests performed: * Ectoparasites Endoparasites Bacteriology Viral Serology Does your facility follow FELASA recommendations for animal monitoring ? * Yes No Frequency of monitoring: * Does the rodent health information submitted with the rodent transfer request correspond to: The entire facility/unit The room where the animals are housed Other Specify Other: * Have any health problems or pathogens been found in your facility within the last 12 months? * Yes No Have any health problems or pathogens been found in the room within the last 12 months? * Yes No Please list the pathogens or health problems: * Please describe actions and treatments that have been administered in your animal facility within the last 12 months: * Please attach an updated health reports, including historical results of the last 18 months and clearly mention the room/s from which animals will be imported. Health reports * Upload More informationFiles must be less than 2 MB. Allowed file types: gif jpg jpeg png html pdf doc docx ppt pptx xls xlsx. Submit
