Nucleic Acid Amplification (Naa) Test Requisition Form
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1Mycobacterium tuberculosis complex
Nucleic Acid Amplification (NAA) Test Requisition
Katherine A. Kelley State Public Health Laboratory
395 West Street, Rocky Hill, CT 06067
Phone: 860-920-6500 / Fax: 860-920-6718
For each clinical respiratory specimen where NAA testing is requested, complete this form, along with
a Clinical Test Requisition, when submitting the specimen to the laboratory. Routine mycobacteria
smear & culture will also be performed.
NAA testing will automatically be done on the first patient specimen submitted for routine
mycobacteria smear & culture found to be Acid-fast Bacilli (AFB) smear positive by the CTDPH
laboratory (the M. tuberculosis complex NAA Test Requisition is not required).
NAA Testing should NOT be ordered:
When clinical suspicion is low (the positive predictive value of the test, the likelihood that the
patient has tuberculosis when the test is positive, is low in such cases).
To determine bacteriologic cure or to monitor response to antituberculous therapy
CTDPH TB Laboratory (860-509-8573) / CTDPH TB Control Program (860-509-7722)
Submission Requirements
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Clinical respiratory specimens (raw unprocessed): sputum, BAL, bronchial wash.
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Patient did not receive antituberculosis therapy, or received less than 3 days of therapy at the
time of specimen collection.
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Specimens must be received by the laboratory within 10 days of collection.
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Test requests must be received within 7 calendar days of specimen receipt in the laboratory.
Submitter Information
Authorized Submitter’s Name: ____________________________________________________
Phone : ________________________________ Fax: _________________________________
Patient Information
Name: ______________________________________________________________________
Patient /Specimen ID #: _________________________ Date of Birth: ____________________
Specimen Information
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□
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Type / Source:
Sputum
Bronchoalveolar Lavage (BAL)
Bronchial Wash
Date Collected: ___________________Other Information______________________________
Rev. 02/25/2014
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