Clinical Supplies Requisition Form - Illinois Department Of Public Health
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1Clinical Supplies Requisition Form
State of Illinois
Illinois Department of Public Health
Date:
Agency Name:
Provider Code:
Contact Name:
(only one code per form)
Program Name:
Agency Address:
Phone:
City:
Fax:
Zip Code:
Please indicate the quantity required. Adjustments may be made based on supply availability.
SYPHILIS / HIV / HCV
BLOOD LEAD
MAILING SUPPLIES
“Exempt Human Specimen”
Blood Collection Tubes
Labels
95 kPa Biohazard bags
Sure Check HIV Accessory
Kit
Alcohol wipes
2 x 8 zip-lock bag (100 each)
Sure Check Rapid HIV
Controls
Lancets
Shipping boxes (room temp)
Sure Check Rapid HIV
Devices
Gauze
Styrofoam cooler and ice packs
Lancets for Determine
Capillary collection tubes
UN3373 labels
Determine HIV Controls
Blood collection tubes
Determine 4th Generation
HIV Devices
UPS RETURN SERVICE LABELS **
OraSure HCV Devices
Carbondale Laboratory
OraSure HCV Controls
Chicago Laboratory
GONORRHEA / CHLAMYDIA
SUBMISSION FORMS
Springfield Laboratory
Female swab collection kit
Blood Lead form
OTHER
Urine collection kit
Communicable Disease form
Urine collection cups
Influenza form
Cary-Blair swabs
Aptima kit for <14 year-old
STD/HIV form with barcodes
Cary-Blair vials
Pertussis kit* (Regan Lowe)
NEWBORN SCREENING
Influenza kit
Newborn Screening blood spot cards
Measles kit*
UPS Next Day Air IDPH Chicago Laboratory labels
Mumps Kit*
Mycobacteriology Tubes (TB)
217-782-2016
* Contact the IDPH Communicable Diseases Program at
** UPS Return Service Labels are only provided for certain tests. Please include provider code or program name.
Fax the completed form to the IDPH Springfield Lab:
Illinois Department of Public Health
Division of Laboratories
825 N. Rutledge Street
Springfield, IL 62702
217-782-6562 (phone)
217-558-3476
(fax)
IDPH Laboratory Use Only:
Date Filled:
Filled by:
Printed by Authority of the State of Illinois
P.O. # 555268 500M
03/2017
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