ࡱ> VXU bjbjC@|| 8P,|t%lLRRR-;\0x%z%z%z%z%z%z%$e'*N%Q--QQ%RR%QRR4%DQx%:#,$R[Zs!j# %%0%#.e*Ze*$e*$v=TD|%%%QQQQe* : Dear Madam/Sir, ___________________ would like to introduce mice from your institute into our facility. The Central Laboratory Animal Research Facility Utrecht would like to be informed on the barrier status where the animals to be shipped are housed. The questions outlined below can help us identify microbiological risks involved in the introduction of your animals to one of our units. Therefore, we kindly ask you to complete this form and return it to below mentioned contact person within our institute. SENDER Name and address of the institute where the mice are housed: Name of contact person: Function: Tel: Fax: E-mail: UNIT What is the name of the unit from which the mice are to be shipped? Is the unit located behind a barrier? If so, please indicate the barrier type (I to IV) according to ILAR classification (Long term holding of Laboratory rodents, ILAR news, Volume XIX, Number 4, 1976) ANIMALS Which animal species besides mice are present in the unit (see table 1)? Which species need to have an SPF status to enter the unit (see table 1)? Please indicate in Table 1 whether microbiological screening is performed on the species housed in the unit? If yes for mice, please provide the most recent health monitoring report not older than 4 months including at least a list of pathogens mentioned in FELASA recommendations and historical results of the past 18 months. Please indicate in Table 1 whether screening results were obtained from immune competent animals? Were species within the unit, other than mice, found positive for mouse pathogens over the last 18 months? YES ( Please indicate in Table 1 and proceed to Sheet 1 to identify mouse pathogens found positive, date when found and subsequent actions taken. NO ( Please indicate in Table 1. BIOLOGICAL MATERIALS Are biological materials (materials of animal origin) injected into the animals of the unit? (see table 1) YES ( please indicate in Table 1 and proceed to question 8 NO ( please indicate in Table 1 Are biological materials tested microbiologically before they are used in animals of the unit? (see table 1) YES ( please indicate in Table 1 and proceed to Sheet 2 to identify mouse pathogens found, the test used and admissibility of the pathogens found into the unit. NO ( please indicate in Table 1 Table 1 (For questions 3, 4, 5a/c, 6, 7, 8) Species SPF status required? (Yes/No)Micro-biological screening? (Yes/No)Screened animals immune competent? (Yes/No)Mouse pathogens found (Yes/No)#Biological materials injected? (Yes/No) Biological materials checked? (Yes/No)@ Mouse# In case of yes, please fill also out sheet 1. @ In case of yes , please fill also out sheet 2. Kind regards, Central Laboratory Animal Research Facility Utrecht Att. Mrs Willeke Bos, import coordinator PO Box 80190 3508 TD Utrecht The Netherlands Tel: +31 30 253 5300 Fax: +31 30 251 0964 E-mail:  HYPERLINK "mailto:w.bos@gdl.uu.nl" w.bos@uu.nl Sheet 1 (For question 6) Mouse pathogen found: in animal species (other than mice): Date found: Action(s) taken and date(s): Mouse pathogen found: in animal species (other than mice): Date found: Action(s) taken and date(s): Mouse pathogen found: in animal species (other than mice): Date found: Action(s) taken and date(s): Mouse pathogen found: in animal species (other than mice): Date found: Action(s) taken and date(s): Mouse pathogen found: in animal species (other than mice): Date found: Action(s) taken and date(s): Mouse pathogen found: in animal species (other than mice): Date found: Action(s) taken and date(s): Sheet 2 (For question 8) Pathogen found test used pathogen admissible (yes/no)     Doc. code: KAM B.1.3.0001.FB Versie: 0003 Geldig d.d.: 20/10/2014 13:29:47 Gem. 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