State Of Michigan - Laboratory Test Requisition Page 2

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STATE OF MICHIGAN - LABORATORY TEST REQUISITION
Microbiology / Virology
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INDICATE TEST REASON
Diagnosis
Surveillance
Outbreak (Complete Section 6)
Other (Specify)
COMPLETE THIS SECTION FOR:
(1)
HIV, SYPHILIS, HEPATITIS, RUBELLA IgM REQUESTS
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PREGNANT?
FOR HEPATITIS B SURFACE ANTIGEN (HBsAg) ONLY
YES
NO
Exposure to someone with Hepatitis B?
COMPLETE THIS SECTION FOR:
(2)
SYPHILIS DFA REQUESTS
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DURATION OF LESION
SPECIFIC SITE:
Days
Months
Years
COMPLETE THIS SECTION FOR:
(3)
RABIES ANTIBODY SEROLOGY REQUESTS
DATE (MM-DD-YY)
DATE OF LAST RABIES VACCINATION
COMPLETE THIS SECTION FOR:
(4)
LYME BORRELIOSIS REQUESTS
ONSET DATE (MM-DD-YY)
State/County/Country of
___________________________________________________
Exposure:
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EARLY DISEASE
LATE DISEASE
Erythema Migrans (5 cm
Symptoms (Example- Rash,
Neurologic
Cardiologic
Rheumatologic
at least in diameter)
Fever, Headache, Joint Pain)
(5)
COMPLETE THIS SECTION FOR:
AEROBIC CULTURE REQUESTS
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GRAM
Aerobe
Microaerophile
Positive
Negative
Variable
Rod
Coccus
Diplococcus
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MacConkey
Oxidase
Catalase
Dextrose
BACTERIAL GROWTH
Positive
Negative
Positive
Negative
Positive
Negative
Oxidation
Fermentation
CHARACTERISTICS:
OTHER:
COMPLETE THIS SECTION FOR:
(6)
OUTBREAK INVESTIGATION
ONSET DATE (MM-DD-YY)
OUTBREAK IDENTIFIER
ORGANISM SUSPECTED (If Applicable)
MDHHS PRIOR APPROVAL: Name, Date
COMPLETE THIS SECTION FOR:
(7)
INFLUENZA TESTING (PCR / CULTURE) REQUESTS
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DATE (MM-DD-YY)
TYPE
LAST INFLUENZA
Flu Mist
Trivalent (Shot)
Other
VACCINATION:
(8)
ADDITIONAL INFORMATION
DCH - 0583
May 02, 2016
By Authority of Act 368, P.A. 1978

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