Form Dhhs 4121 - Special/atypical Bacteriology printable pdf download

1. Last Name

First Name

DO NOT WRITE IN THIS SPACE

N.C. Department of Health and Human Services

State Laboratory of Public Health

LABORATORY NUMBER

4312 District Drive • P.O. Box 28047

2. Patient Number

Raleigh, NC 27611-8047

Submitter Laboratory/Medical Record #: _____________________

3. Address

4. Date of Birth

_______________________________

...........................................................

_______________________________

Zip

PLEASE GIVE ALL

Month

Day

Year

Code

INFORMATION REQUESTED

DATE RECEIVED



5. Race

1. White

2. Black

3. American Indian

4. Asian

DATE SPECIMEN COLLECTED

SPECIMEN TYPE:  ISOLATED ORGANISM**





5. Native Hawaiian/Paciﬁ c Islander

6. Unknown

   SMEAR   CLINICAL*

*Fill out reverse of form



6. Hispanic or Latino Origin:

1. Yes

2. No

3. Unknown



7. Sex

1. Male

2. Female

8. Co. of Residence

EXAMINE FOR:



9. Medicaid Client

Yes



  GC  N. MENINGITIDIS GROUP  H. INFLUENZAE TYPE

If yes, enter #

—

 BORDETELLA PCR  BORDETELLA CULTURE  LEGIONELLA DFA

Dx Code/ICD-9:

 LEGIONELLA CULTURE  REFERENCE ID**

**Describe organism, including biochemical reactions

Federal Tax No. _______________________________________

_______________________________________________________________

Send Report To:

_______________________________________________________________

SPECIMEN SOURCE:

 BLOOD  CSF  URINE  SPUTUM  NP  BRONCH WASH

 BRONCH LAVAGE  BRONCH BRUSH  THROAT

  STERILE BODY FLUID  WOUND–SITE ________________________

 GENITAL–SITE____________  OTHER__________________________

SPECIAL/ATYPICAL BACTERIOLOGY

LABORATORY REPORT (DO NOT WRITE BELOW)

IDENTIFICATION

DATE REPORTED:

GRAM STAIN

DECARBOXYLASES:

REPORT TELEPHONED TO:

OXIDASE

ARGININE

CATALASE

ORNITHINE

 DIRECT FA STAIN FOR _______________________________________

BILE ESCULIN

BASE:

 POSITIVE  NEGATIVE (DFA STAIN IS A PRESUMPTIVE TEST)

BILE SOLUBILITY

ARABINOSE

 CULTURE FOR BORDETELLA

 POSITIVE  NEGATIVE

COAG.: SLIDE

FRUCTOSE

 CULTURE FOR LEGIONELLA

 POSITIVE  NEGATIVE

TUBE

GLUCOSE

ESCULIN

INULIN

 PCR FOR BORDETELLA

 POSITIVE  NEGATIVE

GAS/GLU M.R.S.

LACTOSE

LAP

MALTOSE

%NACL:

6.5%

10%

MOTILITY

MANNITOL

GROWTH TEMP.:

10C

25C

35C

42C

45C

MANNOSE

NITRATE

RAFFINOSE

SEROLOGICAL GROUP:

PYR

SORBITOL

PYRUVATE

SUCROSE

ANTIBIOTIC DISCS:

UREA

TREHALOSE

VANCOMYCIN

TURANOSE

POLYMYXIN B

NOVOBIOCIN

FURAZOLIDONE

OPTOCHIN

Comments:

DHHS 4121 (Revised 10/13)

LABORATORY (Review 10/16)

Form Dhhs 4121 - Special/atypical Bacteriology

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