Forms
Call (404) 639-1510 or (404) 639-1115 for authorization to ship specimens.
Instructions for Completing the Ebola Diagnostic Specimen Submission Form for Quarantined Non-human Primate Materials
- Send specimens by overnight courier (Federal Express preferred). Fax the Tracking Number and packing list to VSPB at (404) 639-1509 or (404) 639-1118.
- Package in accordance with the International Air Transport Association and US Department of Transportation regulations to prevent leakage. See https://www.iata.org/publications/dgr/Pages/manuals.aspx BROKEN LINK and Transporting Infectious Substance Safely Cdc-pdf[PDF – 1.65MB] External
- Label shipment as Diagnostic Specimen and include the following information: test(s) requested, date of collection, laboratory or accession
number, the type of specimen being shipped, and this Specimen Submission Form. - On the outside of the box, specify how the specimen should be stored: Refrigerated, Frozen, or Do Not Refrigerate.
- A payment of $540 US is due upon completion of testing. CDC accepts Visa and Mastercard. Please provide billing information on next page.
- Requires fresh-frozen tissues collected during necropsy
- Be sure to adhere to the Biosafety and Personal Protective equipment requirement when collecting and packaging specimens.
- Tissues required: liver (Spleen can be added but is not required.)
- Collect 2 pieces of at least 1cm3 each, and put them in two separate plastic tubes, correctly labeled. Tube caps should be tight to avoid leakage during manipulation and transportation.
- Put each tube in zip-locked or heat-sealed bag.
- Tissues must be shipped on dry ice or frozen cold pack.
- The accompanying documentation should be in another zip-locked (or sealed) bag to avoid contamination in case of leakage.
Payments can be made at PAY.GOV or by check. Upon submission of this form, an electronic invoice is generated by CDC, and sent to the email address of the sender. (Be sure to send us the completed form from a monitored email address.) Instructions for payment by credit card or by check are included in the electronic invoice document. Note that while samples will be tested as soon as they are received, test results are not released until payment is received.
How to Send This Completed From to CDC
Print this Form and send to:
Centers for Disease Control and Prevention
1600 Clifton Rd. NE
Viral Special Pathogens Branch
Bldg. 15, MS G-14
Atlanta, GA USA 30329
Hit the ‘Send to CDC’ button at the bottom right of page 2. Your computer will generate an email containing the completed information. Hit the ‘Send’ button in your email application to send the email to CDC. Acknowledgement of receipt is not provided.
Print this Form and fax to: (404) 639-1509, or (404) 639-1118
Ebola Diagnostic Specimen Submission Form for Quarantined Non-Human Primates
OMB No. 0920-0263
Exp. 04/30/2016
Please return to: Centers for Disease Control and Prevention, Viral Special Pathogens Branch
Ph: (404) 639-1510 Fax: (404) 639-1118
Email: nonhumanprimates@cdc.gov; dvd1spath@cdc.gov
Site: http://www.cdc.gov/ncidod/dvrd/spb/mnpages/specimen.htm NEED CORRECT DIVISION LINK AND CHECK ON EMAIL ADDRESS–WHO OWNS THEM
- Prior consultation with VSPB staff is required before specimens will be tested. Please call (404) 639-1115 or (404) 639-1510 for assistance.
- Please include a copy of this Form with the specimen shipment, and fax or email a copy using the “Send to CDC” button below.
- Shipments should be labeled as Diagnostic Specimens
- Name and contact info of shipment preparer
- Name and contact information for who should receive test results
- On tubes: date of collection and tatoo/ID number
- Overnight shipping is preferred.
- Please send an email with the shipping number to spath1@cdc.gov CHECK THIS EMAIL ADDRESS
- On outside of box, specify how specimen should be stored: refrigerated, frozen.
Centers for Disease Control and Prevention
ATTN STAT LAB: VSPB, Unit #70
1600 Clifton Road NE
Atlanta, GA 30333
Phone: (404) 639-1115 (VSPB Lab) or
(404) 639-1118 (VSPB fax)
Package in accordance with IATA regulations to prevent leakage. See: http://emergency.cdc.gov/labissues/#shipping SHOULD THIS BE THIS LINK? https://emergency.cdc.gov/labissues/specimens_shipping_instructions.asp
You must have internet access and an email address to submit this form electronically.
Upon hitting the ‘Submit by Email’ button, a PDF is created, attached to an email, which you should then send to the addresses which appear in the address Leader; you may also cc: others.
Acknowledgement of receipt by CDC is not provided.
Specimen Submission Form
Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-0263.