Zika Virus Testing And Report Form Page 2
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6PUBLIC HEALTH LAB
COUNTY OF LOS ANGELES
USE ONLY
DEPARTMENT OF PUBLIC HEALTH
PUBLIC HEALTH LABORATORIES
12750 Erickson Avenue
California Certified Public Health Laboratory #335637
CLIA #05D1066369
Downey, CA 90242
Phone 562-658-1330/1300
Fax 562-401-5999
FAX 62 401 4999
ZIKA TEST REQUISITION
THIS PART OF THE FORM MUST BE ACCOMPANIED BY PAGE 1
A SEPARATE TEST REQUEST MUST BE COMPLETED FOR EACH SPECIMEN TYPE
ALL FIELDS ON THIS PART OF THE FORM MUST BE COMPLETED
FAILURE TO COMPLETE ALL FIELDS WILL RESULT IN SPECIMEN REJECTION OR DELAY
REQUIRED PATIENT INFORMATION
Patient Name (Last, First, Middle Initial)
Date of Birth
Sex
(mm/dd/yyyy)
Male
Female
Other
Patient Address- Number, Street, Apt #
City
State
ZIP Code
Patient Home Telephone Number
Patient Work Telephone Number
Patient Cell Number
MRN/Patient ID
Requesting Physician (Last, First)
Previous Vaccination?
Tick-borne Encephalitis
Yellow Fever
Japanese Equine Encephalitis
Previous Testing? Chikungunya
Pos
Neg
Pending
Not done
Dengue
Pos
Neg
Pending
Not done
REQUIRED – Test(s) Requested
REQUIRED - Specimen Source
Each specimen type requires a
separate test request form
Arbovirus serology panel (serum, cord blood, or CSF)
Serum
Includes Zika, Chikungunya, and Dengue
Urine
Cord Blood
Arbovirus RT-PCR (serum, cord blood, urine, body fluids, and fresh/frozen/fixed tissue)
Amniotic Fluid
Includes Zika, Chikungunya, and Dengue
Fetal tissue
(specify type): ______________________
Immunohistochemistry (fixed tissue or paraffin block)
Placenta
CSF (if collected for other purposes)
Histopathology (fixed tissue or paraffin block)
REQUIRED
Date specimen collected: _____________
Time: _____________
ZIKA VIRUS TESTING AND REPORT FORM AND INSTRUCTIONS - ZikaInfoTestReq (6/23/16)
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CONFIDENTIAL – This material is subject to the Official Information Privilege Act
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