Form Fqa-063 - Microbiology Submission - Arizona Department Of Health Services
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1Bureau of Laboratory Services
FOR ASPHL USE ONLY
th
250 N. 17
Avenue, Phoenix, Arizona 85007-3231
Tel: (602) 542-1188 Fax: (602) 364-0758
Victor Waddell, Ph.D., Bureau Chief
All fields highlighted in yellow are required for specimen processing. In addition, at least one test must be requested.
PATIENT INFORMATION (Patient address and telephone number are required, when available, per R9-6-204(B))
Last name:
First name:
Middle:
DOB:
Age:
Sex:
M
F
Patient ID:
Street address:
City:
State:
Zip:
County:
Telephone Number:
Ethnicity:
Hispanic
Y
N
Race:
White
African American
Asian
American Indian/Alaska Native
Other
Date of first symptoms:
Date of death (DOD):
SUBMITTING AGENCY
Agency name:
Agency ID code:
Street address:
City:
State:
Zip:
County:
Contact name:
Tel:
ORDERING PROVIDER INFORMATION
Provider name:
Tel:
Agency name:
Tel:
Street address:
City:
State:
Zip:
County:
Clinical or Reference:
Broth
Isolate
SPECIMEN INFORMATION
Collection date:
Blood/Serum
Acute
Convalescent
Random
CSF
Whole Blood/Plasma (anticoagulant)
Purple Top (EDTA)
Green Top (Heparin)
Gray Top (NaF)
Other:
Swab, site:
Urine
Sputum
Induced Sputum
Stool
Tissue, specify:
Wound, site:
Swab or Tissue (circle)
Body fluid, specify:
Other, specify:
Reason for testing:
Diagnostic
Screening
Surveillance
Post Mortem
Outbreak:
Submitting Lab Findings or Preliminary ID:
Refer to the Guide to Laboratory Services for more information on specific testing
+
Virology/Serology
Bacteriology
Parasitology
:
Chikungunya virus (IgM EIA/PCR)
*Bordetella pertussis
Blood/Tissue
Dengue virus (IgM EIA/PCR)
*Clostridium botulinum toxin
Giardia/ Cryptosporidium
*Corynebacterium diphtheriae
Enterovirus culture
+
for malaria testing, attach patient travel history
CRE
*D68
Enteric culture
Mycobacteriology:
Hantavirus IgG & IgM EIA
Shigatoxin
Culture
Influenza PCR
Haemophilus influenzae
ID (Referred Culture)
*Avian lineages
Legionella spp.
*Nucleic Acid Amplification
*anti-viral resistance
Leptospira spp.
Smear
General/Respiratory Virus ID
Listeria spp.
Susceptibility
Suspect agent: ______________
Neisseria meningitidis
Salmonella spp.
Select Agents:
*Measles (IgM EIA/PCR/Culture)
Shigella spp. (serogrouping only)
*Bacillus anthracis
*MERScoV PCR
Vibrio
*Brucella spp.
*Mumps (IgM EIA/PCR/Culture)
VISA/VRSA
*Burkholderia spp.
Norovirus PCR
Yersinia spp.
*Francisella tularensis
Q-Fever (Phase I & II) IgG IFA
CIDT Confirmation
*Orthopox
Spotted Fever Group IgG IFA (RMSF)
Organism ID: ________________
*Coxiella, Q-Fever PCR
Rubella IgM EIA
*Yersinia pestis
WNV IgM EIA & SLE IgM EIA
Other: _________________________
*Zika virus (IgM EIA/PCR)
Chemistry:
Other: ___________________
Toxicology Surveillance Panel
*
Prior notification is required. Call (602) 364-3676 After Hours (480) 303-1191
For information on shipping specimens and isolates to the state lab:
Microbiology laboratory results may be made available to the local jurisdictional health department for review per A.R.S. §36-160
FQA-063, V.06 Date Approved: 09.18.2017
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