Emerging Disease Discovery Support for Diagnostic Fees

SHIC will support diagnostic fees for emerging disease discovery with approved cases. This form is to be completed by the diagnostician* after identifying a qualifying, undiagnosed case with due diligence (including notifications of possible FAD). It also serves as application for financial support for laboratory fees on behalf of the submitter**. All clinical and laboratory information can be submitted anonymously (without submitter** or other identifiers) will be kept confidential, and will not be shared without permission of the submitter**. A submitter** consent form will be signed and held by the Diagnostic Laboratory of record as part of the permanent case file. After completing the form below, a panel of three diagnosticians from public institutions will review the information and contact the diagnostician* of record within 48 hours with a decision or request for additional information.

Case ID (required):

Date:

Diagnostician* (required):

Your Email (required):

Laboratory(required):

Submitter:

Case information as currently known - use as much space as needed or attach documentation.

History:

Clinical Signs:

Laboratory Results (include a summary here and attach diagnostic reports):

Why do you think this could be an emerging infectious disease?

* The veterinary laboratory diagnostician is the person responsible for the original laboratory investigation and has evaluated laboratory results, lesions and case history to assure the basic criteria for the request for funding are met.
**The submitter is the attending veterinarian with direct contact and knowledge of the animals.