Form Il 482-1039 - Communicable Diseases Laboratory Test Requisition - Illinois Department Of Public Health Page 2
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1
2Communicable Diseases
Laboratory Test Requisition
State of Illinois
Illinois Department of Public Health
REFERRED CULTURE INFORMATION
Agent Suspected ______________________________________________________________________________________
Morphology __________________________________________________________________________________________
Carbohydrate Reactions ________________________________________________________________________________
Other Biochemical Reaction _____________________________________________________________________________
Commercial Kit Used ___________________________________________________________________________________
Tentative Identification __________________________________________________________________________________
Other Pertinent Information
INSTRUCTIONS
The Illinois Department of Public Health laboratory requisition form titled, “Communicable Diseases Laboratory Test Requisition,”
is designed to accompany the specimens submitted to the Department’s laboratories by approved submitters for communicable
diseases testing, including parasitology, bacteriology, enterics and virus.
DEFINITION - Submitter - Entity that sends specimens to be tested.
SUBMITTER INFORMATION - Enter the name of the organization/hospital OR submitter code (if you have one) requesting
the test, the ordering contact person/clinician’s last name (important so that test results may be routed correctly), the address
of the organization/hospital requesting the test, and the complete submitter’s phone number and FAX, including area code.
PATIENT INFORMATION - Print the patient’s full name. The patient’s ID# is an optional field for a locally assigned patient
number completed at the discretion of the submitter. If applicable, enter the patient’s Medicaid identification number. Enter the
patient’s date of birth, if known. If the date of birth is entered, the age may be left blank. Enter sex, race, ethnicity as indicated
by the patient. Enter the patient’s complete address including apartment or suite number, city/town, state and five digit ZIP
code.
TEST REQUEST INFORMATION - Enter the date the specimen was collected. This is a REQUIRED field. If applicable, enter
the date of patient’s illness onset. Please print the initials of person completing the requisition form and the initials of person
collecting the specimen. Enter specimen collection time.
To request a test, fill in appropriate box. Fill in box for source and reason. If not listed, use “other” and write appropriate test,
source or reason.
Chicago Laboratory
Springfield Laboratory
Carbondale Laboratory
2121 W. Taylor St.
825 N. Rutledge St., P.O. Box 19435
1155 S. Oakland Ave., P.O. Box 2797
Chicago, IL 60612
Springfield, IL 62794
Carbondale, IL 62901
312-793-4760
217-782-6562
618-457-5131
Printed by the Authority of the State of Illinois
IL 482-1039
P.O.#5513245 100M
10/14
IOCI 15-413
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