Pathology Submission Form
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Necropsy / Biopsy Date      	      Prosector:       	   Lab Accession#       		
Investigator/Dept            Contact Name            Contact tel#            
Contact email                  IACUC #      	      Program Code:       	        
Fund Code:                Project code:       Department code:       Fiscal contact:      
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Mouse Strain/Geno               Mutant Y  /  N (If yes, complete mutant info form) Mouse ID#          	 
Source                 Sex  F  /  M	Color BLK / Agouti / ALB:            Age / DoB      Found Dead   Y  /  N 	Euth  CO2  /  Isoflurane  /  Cerv. Disloc.  Other:  		
Ancillary Tests Requested(check ‘’ applicable boxes) 
CBC / diff	Clin Chem	UA	Serology	Micro	Ecto-parasites	Endo-parasites					
											
Bleeding Method/Site  Retroorbital  /  Saphenous  /  Tail  /  Cardiac  /  Other:  		
History and Clinical Signs (Include background strains, special diets, drug treatments; reason(s) for submission; clinical signs):       
																																																				
----------------------------------------Below To Be Completed During Necropsy--------------------------------------------
Fixative:    Formalin   /   Bouins   /   Alcohol   /  Other:  		
Gross Findings (Include weights/measurements for lesions, and diagrams to indicate external lesions whenever possible.):  
Body Condition (circle): 	1 (emaciated)	  2	    3 (normal)         	4	           5 (obese > 45g)
Body Wt	Liver 	Spleen	Heart	Kidneys			
							
ID Tags/#’s (save with tissues if possible):    SubQ ID chip saved  Punch:  R    	                 L
Description of Gross Findings:																																																																																																																																																									

Mouse Lymph Nodes

1.  Superficial Cervical Nodes
2.  Deep Cervical Nodes
3.  Mediastinal Nodes
4.  Axillary Nodes
5.  Branchial Node
A.  Thymus
B.  Spleen
6.  Pancreatic Node
7.  Renal Nodes
8.  Mesenteric Nodes
9.  Inguinal Node
10. Lumbar Nodes
11. Sacral Nodes
12. Sciatic Nodes
NS	Popliteal Node – Behind Knee

From Dunn 1954  JNCI

Additional information (continued from front page)