Microbiology Infection Surveillance Requisition Form
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1Diagnostic & Scientific Center
MICROBIOLOGY INFECTION SURVEILLANCE REQUISITION
9, 3535 Research Road NW
Calgary, Alberta T2L 2K8
Phone 403-770-35001-800-
PROVINCE
PERSONAL HEALTH NUMBER (PHN)
REGIONAL HEALTH
661-3450
RECORD NUMBER
___ ____ ____ ____ ____ - ____ ____ ____ ____
Shaded areas are required Information
ORDERING PHYSICIAN – (Apply CLS Dr. Stamp Here)
PATIENT LAST NAME
FULL FIRST NAME
MIDDLE NAME
Last Name / Full First Name:
PATIENT ADDRESS
CITY, PROVINCE
POSTAL CODE
5 Digit Client #:
CHART
GENDER
DATE OF BIRTH
PATIENT PHONE NUMBER
Alpha Suffix Provider #:
NUMBER
-
__ __ __ __ / __ __ __ / __ __
__ __ __ -- __ __ __
__ __ __ __
Y Y Y Y
M M M
D D
COPY TO:
1) ______________________ _______________________ ____________________
Last Name
Full First Name
Office Address/Location
2) ______________________ _______________________ ___________________
EI # _________________________________________________________________
Last Name
Full First Name
Office Address/Location
ARO SURVEILLANCE
STERILITY
Specimen (s):
Test(s):
Tissue Bank Donor
[M STERILE]
Bone Bank ID#
______________________________________________
[M MRSA]
Nose / Nasal
MRSA
[M STERILE]
Skin Bank ID#
_______________________________________________
[M STERILE]
Cadaveric Blood ID#
[M NOSE]
_________________________________________
S. aureus Carrier
Tissue Bank Recipient
[M ANO2/M FUNGAL ]
Bone ID#
____________________________________
[M W OUND]
[M MRSA]
Rectal
MRSA
Skin ID#
_____________________________________
Source/Site – Specify
___________________________
[M CPO]
Stool
Carbapenemase Producing Organism
Copy to Southern Alberta Tissue Program (SATP)
Eye Donor
[M VRE]
Wound
VRE
Lions Eye Bank #:
________________________________
Specify Site
________________
[M STERILE]
Corneal Limbus
[M ANO2]
Vitreous
Urine
[M ARO]
Other antibiotic resistant bacteria -
[M STERILE]
Corneal Culture Media
Eye Recipient
Other – Specify:
Specify Organism
______________________
Corneal Rim #:
________________________________
(Requires Micobiologist on call approval
[M STERILE]
Pre-inoculated Chocolate Plate
403-770-3757)
[M STERILE]
Pre-op Eye Swab
Transfusion medicine
[M STERILE]
AUWB
[M STERILE]
SCD
[M STERILE]
Other – Specify:
__________________________________
Fluid Reagent Sterility:
ENVIRONMENTAL STERILITY
[M STERILE]
Pharmacy – Specify Sample:
[M STERILE]
Injectable Fluids -
Nuclear Medicine
[M STERILE]
Attest
[M STERILE]
Isotope Lab
Sporestrip
Steam
Dry heat
Gas
[M STERILE]
TPN Broth-Sample # _______________________
[M STERILE]
CIVA Broth-Sample #_______________________
[M STERILE]
POSITIVE ATTEST B.I. SUBCULTURE:
Specify Sample:
Sterilizer # : _________________________
Load #:___________
Lot # : ______________________________________
Airfall Plate
[M STERILE]
*
Other - Specify: ____________________________
Specify Site: ______________________________________
Laminar Airflow Hood
[M STERILE]
Specify Hood: ____________________________________
[M STERILE]
* Other tests ordered require approval of a Microbiologist. Contact: Microbiologist on Call 403-770-3757.
Endoscopy Wash
Specify:
Model #________________________________
Serial #________________________________
Collected By:
Accession #
Date & Time Collected:
(required)
MICROBIOLOGY 7828M (Rev 20151001)
Laboratory Information Centre 403-770-3600
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