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Vrdl General Purpose Laboratory Submittal Form - California Department Of Public Health

California Department of Public Health – Viral and Rickettsial Disease Laboratory

INFLUENZA Reference Examination Supplemental Information

1. Fill out one VRDL General Purpose Laboratory Submittal Form per sample

2. On the General Purpose Submittal form in the “Test(s) Requested” space enter either

Typing/subtyping, Strain Typing or Antiviral Resistance

3. Complete the information below and send one copy with the individual submittal forms (last name,

first name and local specimen # will be used to link both forms together)

Last Name: __________________________________ First Name: _____________________

Local Specimen # ________________

Occupation:________________________________

Test Requested: [ ] Typing/Subtyping

[ ] Strain typing

[ ] Antiviral Resistance

Original Source of Specimen: ______________________________________________________

Description of Submitted Material:

[ ] Isolate Supernatant

[ ] Original Specimen

[ ] Nucleic Acid (NA)

[ ] other (describe):______________________________________________________________

Shipped Temperature: [ ] Room temp

[ ] Cold Pack

[ ] Frozen

Molecular Identification Methods Used by Local Laboratory

rt RT-PCR Platform: _____________________________________________________________

rt RT-PCR Results (include Ct values): ______________________________________________

Source of Molecular Reagent:

[ ] VRDL

[ ] CDC

[ ] other _______________________________________________________________

Submitter Secure Fax# to report results (_____) _____-______

(see reverse side for submittal instructions and space for additional details)

Vrdl General Purpose Laboratory Submittal Form - California Department Of Public Health