ࡱ> TVS5@ ?bjbj22 ,PXX H       &&&8^$ZZZZZ999MOOOOOO$Rs 95999s  ZZ{{{9" Z ZM{9M{2{  ZN `S6 &[R<0| |     | d99{99999ssDbY"bDuring quarantine, this form must remain posted in the room housing the animals. Following release from quarantine, it must be filed by the Compliance Manager. Primary Investigator: _______________________________________Contact Number: ______________________ Species name (if applicable, strain/mutation): ________________________________________________________ Location of quarantine (room #): __________________________________________________________________ Vendor/Shipper: ____________________________________Vendor/Shipper Contact: _______________________ Date Animals Received: ___________________________ Health Report Included: _________ Yes __________No Total Number of Animals Ordered: ________________ Total Number of Animals Received: __________________ Health/Condition of Animals Upon Arrival: _________________________________________________________ _____________________________________________________________________________________________ List below the health status for each day of quarantine. Date:Health Status (BAR: bright, alert, responsive)NotesInitials of InspectorDay 1Day 2Day 3Day 4Day 5Day 6Day 7Day 8Day 9Day 10 The following signatures authorize the animals to be removed from quarantine. The animals will be moved by: ______________PI ______________ACF Supervisor. Special Instructions: ____________________________________________________________________________ _____________________________________________________________________________________________ Primary Investigator: _________________________________________________ Date: __________________ ACF Supervisor: ____________________________________________________ Date: ___________________ Sick/Injured Animal: ____________________________________________________________________________ Date: _________________ Name of Person Identifying Problem:_________________________________________ Please describe below the illness or injury:  Date of Evaluation By Veterinarian: _______________ Comments on Evaluation by Veterinarian: Recommendation of action by Veterinarian: _________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Veterinarian Signature: ______________________________________________ Date: _______________________ PI Signature: ______________________________________________________ Date: _______________________ Veterinary Care Quarantine Intake Form See back for Veterinary Care OPcs   # 3 4 Q g h n 7 8 N [ {p{h]RhRh[Jhj~CJaJh[JhCJaJhCJaJh[JhzkCJaJh CJaJh[JhyCJaJhF^}CJaJhiCJaJh[JhQ3,CJaJhyCJaJh[Jhz{CJaJhj~#h *Uhj~5CJOJQJ^JaJhb5CJOJQJ^JaJh 5CJOJQJ^JaJh5CJOJQJ^JaJ   o 8  i  5 ; Q $Ifgd[Jdhgdzkdhgd[Jdhgdz{$a$gdQ3,>    ! - . 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