Form PHS-3 __ __ __ _Request for Field Microbiology Testing  __ __           |S-   -      |
Site:Code |__|__|__|__| Site Name:________________  Company |__|__|_________ |            |
             __ __          __ __ __ __ __ __       __ __                        Lab.Ref.
Species/Type|__|__| Houses |__|__|__|__|__|__| Age |__|__| weeks/days  Date Hatched __/__/__
Sampled by :__________________ Date Sampled  __/__/__  

Tests Required (Delete as appropriate): Salmonella/Campylobacter/____________________________
---------------------------------------------------------------------------------------------
Samples submitted  (please attach list if appropriate):                  
                           Number of Samples                              Number of Samples
Hatchery culled chicks-  - - - -|___|          Environmental Sample - - -  - - |___|
D.O.A. Chicks  - - - - - - - - -|___|          
Chick Box Liners - - - - - - - -|___|                                           ___
1-4 Day Chick Mortality - - - - |___|          Feed  - - - - - - - - - - - - - |___|           
Cloacal Swab- - - - - - - - - - |___|          Feed Ingredients  - - - - - - - |___|
Composite Faeces  - - - - - - - |___| 
Litter - - - - - - - - - - - - -|___|                                           ___
Carcases - - - - - - - - - - - -|___|          Other:_________________________ |___|

Comments_:________________________________________________________________________________
For Office Use Only : Date Received  __/__/__ Condition __________ Media System  |___|
------------------------------------------------------------------------------------------
Form PHS-3      Salmonella                  |             HINTS FOR GOOD SAMPLES
                                            |             ======================
                                            | 1. Plan for samples to arrive on a week-day.
                                            | 
                                            | 2. Use appropriate sample numbers and 
URGENT      PATHOLOGICAL SPECIMEN     (S)   |    containers - consult laboratory if in 
======      =====================           |    any doubt.
    -------------------------------         |
To:|                               |        | 3. Package in a secure leak-proof manner.
   | POULTRY HEALTH SERVICES       |        |     If not possible to dispatch immediately 
   | Lakeside Veterinary Centre    |        |    keep samples refrigerated (not frozen).
   | Marsh Lane                    |        |
   | Hemingford Grey               |        | 4. Complete this form, fold in 4 and place
   | Huntingdon,                   |        |    in a "Documents Enclosed" pouch with the
   | Cambs                         |        |    address visible. Peel off backing and
   | PE18 9EN                      |        |    stick to outside of package.
    -------------------------------         |
____________________________________________|_____________________________________________