Log Sheet

Form Approved

OMB No. 0920-xxxx

Expires xx/xx/xxxx

STUDY NAME: LOG SHEET

Canine Leptospirosis Surveillance, Puerto Rico Clinic/Shelter Name: ________________________________________

Study ID (ex. A003)	Clinic/Shelter ID	Owner Last Name (write “N/A”, if shelter)	Dog's Name	Gender	Date Illness Onset (mm/dd/yy)	Lepto Rapid Test #1	Lepto Rapid Test #2*	Specimens Collected for Shipment Select all that apply.
Place ID label here				☐ M ☐ F ☐ MC ☐ FS		Date: ___/___/___ ☐ Negative ☐ Positive	Date: ___/___/___ ☐ Negative ☐ Positive	Date: _____ /_____ /_____ ☐ Blood ☐ Blood Culture ☐ Serum ☐ Urine Culture ☐ Urine (cysto) ☐ Kidney Tissue ☐ Urine (free catch) ☐ Kidney Culture
Place ID label here				☐ M ☐ F ☐ MC ☐ FS		Date: ___/___/___ ☐ Negative ☐ Positive	Date: ___/___/___ ☐ Negative ☐ Positive	Date: _____ /_____ /_____ ☐ Blood ☐ Blood Culture ☐ Serum ☐ Urine Culture ☐ Urine (cysto) ☐ Kidney Tissue ☐ Urine (free catch) ☐ Kidney Culture
Place ID label here				☐ M ☐ F ☐ MC ☐ FS		Date: ___/___/___ ☐ Negative ☐ Positive	Date: ___/___/___ ☐ Negative ☐ Positive	Date: _____ /_____ /_____ ☐ Blood ☐ Blood Culture ☐ Serum ☐ Urine Culture ☐ Urine (cysto) ☐ Kidney Tissue ☐ Urine (free catch) ☐ Kidney Culture
Place ID label here				☐ M ☐ F ☐ MC ☐ FS		Date: ___/___/___ ☐ Negative ☐ Positive	Date: ___/___/___ ☐ Negative ☐ Positive	Date: _____ /_____ /_____ ☐ Blood ☐ Blood Culture ☐ Serum ☐ Urine Culture ☐ Urine (cysto) ☐ Kidney Tissue ☐ Urine (free catch) ☐ Kidney Culture
Place ID label here				☐ M ☐ F ☐ MC ☐ FS		Date: ___/___/___ ☐ Negative ☐ Positive	Date: ___/___/___ ☐ Negative ☐ Positive	Date: _____ /_____ /_____ ☐ Blood ☐ Blood Culture ☐ Serum ☐ Urine Culture ☐ Urine (cysto) ☐ Kidney Tissue ☐ Urine (free catch) ☐ Kidney Culture
Place ID label here				☐ M ☐ F ☐ MC ☐ FS		Date: ___/___/___ ☐ Negative ☐ Positive	Date: ___/___/___ ☐ Negative ☐ Positive	Date: _____ /_____ /_____ ☐ Blood ☐ Blood Culture ☐ Serum ☐ Urine Culture ☐ Urine (cysto) ☐ Kidney Tissue ☐ Urine (free catch) ☐ Kidney Culture

*Lepto Rapid Test #2: Perform test #2 if the first lepto rapid test was negative and blood was collected <7 days after symptom onset.

Gender: M = male MC = male, castrated

F = female FS = female, spayed

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