NECROPSY FORM

Date Submitted: ____________________ Necropsy #: ________________________

RESEARCH ANIMAL RESOURCES, DIVISION OF COMPARATIVE MEDICINE 624-9100

NECROPSY REQUEST FOR EXPERIMENTAL ANIMALS
(To be completed by investigator. Print off to use)

Investigator and Contact _____________________________________ Department ____________________

Phone _______________ Campus Mail __________________________________________________

Protocol Number____________________ Billing Name__________________

Animal: ID# __________ Species/Strain _______________________ Sex ______ Number ______

Age ____________ Date of Birth (if known)______________ Date Purchased _______________

Purchased From __________________ Where Housed ___________________ Diet ________________

Date/Time of Death ___________ Method of Euthanasia ________Post-Mortem Interval _________

Necropsy Requested by _________________________ Department ______________________________

Description of Experiment _________________________________________________________________

_______________________________________________________________________________________

Why do you want these animals necropsied? (Please be specific)
_______________________________________________________________________________________

_______________________________________________________________________________________

Gross Findings (For RAR USE ONLY) ______________________________________________________

_______________________________________________________________________________________

Ancillary Procedures

HEM MICRO SERO PARASIT SERUM CHEM U/A PHOTO TISSUES FROZEN TISSUES FIXED

. . . . . . . . .

HEM	MICRO	SERO	PARASIT	SERUM CHEM	U/A	PHOTO	TISSUES FROZEN	TISSUES FIXED
.	.	.	.	.	.	.	.	.

Revised 6/00