Microbiology Test Request Form - Unified State Laboratories printable pdf download

MICROBIOLOGY TEST REQUEST FORM

FOR USLPH USE ONLY

UNIFIED STATE LABORATORIES: PUBLIC HEALTH

LAB#

4431 SOUTH 2700 WEST

TAYLORSVILLE, UTAH 84129

TELEPHONE: (801) 965-2400, (801) 965-2561

FAX: (801) 965-2551

DATE STAMP

TESTING WILL NOT BE PERFORMED UNLESS FORM IS COMPLETELY FILLED OUT. PLEASE PRINT CLEARLY FOR ACCURACY.

PATIENT INFORMATION:

SAMPLE STATE OF ORIGIN:

ZIP CODE:

UTAH PATIENT/SAMPLE COUNTY OF ORIGIN:

DATE OF BIRTH (mm/dd/yyyy)

AGE

SEX

________/_________/________

PATIENT NAME (Last, First):

Your patient ID number if

you would like it included on

the report for your records.

PATIENT ID #

ETHNICITY

RACE

[ ] Hispanic

[ ] White

[ ] Black or African American

[ ] American Indian or Alaska Native

[ ] Non-Hispanic

[ ] Asian

[ ] Native Hawaiian or other Pacific Islander

PROVIDER INFORMATION

SPECIMEN COLLECTION DATE AND TIME

Enter if available for TB program.

Provider Code:

Physician: _____________________________________________________

Provider Phone: _________________________________________________

(mm/dd/yy) ________/________/_________

Contact the Lab if you do

not know your Provider

Provider Email: __________________________________________________

Code.

Secure Fax #: __________________________________________________

Time: __________________

SPECIMEN SOURCE/SITE (CHOOSE 1):

[ ] Blood

[ ] Environmental (specify):______________

[ ] Plasma

[ ] Throat swab

Please be as specific as

[ ]

Bronchoalveolar lavage

[ ] Fluid (specify):_____________________

[ ] Rectum

[ ] Tissue (specify):______________

possible as to specimen

[ ] Bronchial aspirate

[ ] Food (specify):_____________________

[ ] Scab

[ ] Tracheal aspirate

source/site.

For Example

[ ] Bronchial wash

[ ] Isolate (source):____________________

[ ] Serum

[ ] Urethra

[ ]

Cerebrospinal Fluid

[ ] Lesion (site):______________________

[ ] Skin

[ ] Urine

[ ] Cervix

[ ] Nasal (aspirate /swab / wash)

[ ] Sputum (natural / induced)

[ ] Vagina

[ ] Endotracheal aspirate

[ ] Nasopharyngeal swab

[ ] Swab (specify site):________________

[ ] Vomitus

[ ] Endotracheal wash

[ ] Nasopharyngeal-throat swab

[ ] Stool

[ ] Wound/Abcess

Swab is unacceptable for

[ ] Other (specify): ________________

culture.

BACTERIOLOGY/TUBERCULOSIS TESTS

IMMUNOLOGY / VIROLOGY TESTS

[ ] Bacterial Culture

[ ] Chlamydia and Gonorrhea by NAAT

[ ] Measles

Please mark either culture

[ ]

Bacterial ID / Referral

[ ] Mumps

[ ] Symptomatic

[ ] Patient request

or referral and include ID if

[ ] QuantiFERON-TB Gold

Presumptive ID:_______________

[ ] Pregnancy test only visit

[ ] IUD insertion

you have already

[ ] Mycobacterial culture

QuantiFERON specimen required information

[ ] Positive CT in the past 12 months

[ ] Cervical friability

performed testing.

[ ] Mycobacterial referral

[ ] Client meets screening criteria

[ ] Mucopus

Incubation start time______________Blood draw date/time:__________

Presumptive ID:_______________

[ ] New partner in the last 60 days

[ ] PID

Incubation end time_______________ Signature:___________________

Incubation at 37

[ ] Other (specify): _____________

°C completed? YES NO

[ ] >1 partner in the last 60 days

[ ] Urethritis

BIOTERRORISM TESTS

[ ] Colorado tick fever

[ ] Syphilis IgG EIA

(Notify Lab before submitting)

[ ] Cytomegalovirus

Syphilis specimen required information

[ ] Bacillus anthracis

[ ] HBsAb (antibody)

[ ] Previous positive RPR

[ ] Brucella spp.

[ ] HBsAg (antigen)

[ ] Previous positive IgG EIA

[ ] Brucella spp. Microagglutination

[ ] HCVAb (antibody)

[ ] Previous positive FTA/TPPA

[ ] Burkholderia mallei/pseudomallei

[ ] Varicella zoster virus

[ ] Clostridium botulinum culture & toxin

[ ] HIV EIA

[ ] Virus identification

[ ] Coxiella burnetii

Virus suspected:____________________

HIV specimen required information

[ ] Francisella tularensis

[ ] West Nile virus IgM (Human)

[ ] Repeat testing of reactive

[ ] F. tularensis microagglutination

[ ] Rapid test Reactive confirmation

[ ] Orthopox virus

[ ] Hantavirus (Sin Nombre)

[ ] Vaccinia virus

[ ] Herpes simplex virus with typing

[ ] Varicella zoster virus

[ ] Influenza A & B virus PCR

[ ] Variola virus

(with subtyping)

[ ] Yersinia pestis

[ ] Hospitalized w/ Influenza-like illness

[ ] Yersinia pestis hemagglutination

[ ] Sentinel site

[ ] Other (i.e., cluster investigation)

[ ] Other (specify): _____________

Cluster location: ____________________

Other reason for testing: ____________

ADDITIONAL INFORMATION: MARK ALL THAT APPLY

[ ] Acute Serum (mm/dd/yyyy) _____/_____/_____

[ ] Disease suspected:_______________________

[ ] Exposure

[ ] Convalescent Serum (mm/dd/yyyy) _____/_____/_____

[ ] Employee medical screen

[ ] Work related

[ ] Presumptive ID:____________________

[ ] Other (specify):_____________________

[ ] Pre-natal / Perinatal

COMMENTS:

Microbiology Test Request Form - Unified State Laboratories

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