Free Patient's Name (Last) (First) - Indiana

PARASITOLOGY
State Form 13053 (R5/10-07) CLIA Certified Laboratory #15D0662599

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INDIANA STATE DEPARTMENT OF HEALTH LABORATORIES th 550 W. 16 Street, Suite B Indianapolis, IN 46202-2203 (317) 921- 5500 Age* County* Address Sex*

Patient's Name (Last)* Patient's Address* Attending Physician (if not included below)

(First)*

(Please Print or Type)

Required Specimen Information Date Collected*________________________________ First Patient Specimen?* Type: * Feces Yes Purpose:* Diagnostic Release ___________ ______________ (specify) Carrier Outbreak No

Name and Address for Report* _______________________________________________ _______________________________________________ _______________________________________________ ________________________________IN_____________
City Zip Code

Contact* Person_________________________________________ Phone* Number ( Fax* Number ( )__________________________________ )__________________________________
*REQUIRED INFORMATION

Other Comments:____________________________________ _____________________________________________

Instructions are on the reverse side

LABORATORY REPORT Date Received_______________

Do not write below this line

Lab No. ______________

Date of Final Report_____________

No trophozoites, cysts, or ova of intestinal parasites found Comments_____________________________________________________________________________________ Unsatisfactory ­ Please resubmit for reasons below:____________________________________________________ ______________________________________________________________________________________________ Copy to ISDH Epidemiology Resource Center

PARASITOLOGY Submission of Specimens ­ ISDH Container No. 4A ­ Intestinal Parasites: Examination of fecal specimens for amoeba and other protozoa. Cryptosporidium sp. will be tested upon request. IMPORTANT: Mailing container contains one request form, a plastic spoon, and two media bottles: one contains 10% Formalin and the other (PVA) Polyvinyl Alcohol fixative. A. Both solutions are poisonous if taken internally. Do not eat or drink solutions. Any spills should be absorbed with paper towels and discarded as trash. If fluid contacts the skin, wash with soap and water. If fluid contacts eyes, flush with water for several minutes. B. Kit must be used by the expiration date stamped on the outside of the mailing label. Kits exceeding the expiration date will not be tested. C. Write NAME and SPECIMEN COLLECTION DATE on both the REQUEST FORM AND COLLECTION BOTTLES. Without this complete information the specimen WILL BE CONSIDERED UNACCEPTABLE AND WILL NOT BE TESTED. D. Carefully proceed as follows.
INSTRUCTIONS

1. Fully complete the upper half of the request form. Please type or print clearly. 2. Feces must be added to EACH bottle. 3. Collect feces in a clean bedpan, plate, cardboard container, or paper or plastic cup. (DO NOT MIX URINE WITH FECES) 4. Using the plastic spoon, place a portion of feces the size of a quarter into EACH bottle. 5. Carefully break up and stir the feces in each bottle. Screw the caps on tightly and shake vigorously to further blend the specimen. Place into metal container and tighten screw caps. 6. DISCARD THE PLASTIC SPOON PROPERLY --------- DO NOT return the spoon to the laboratory. 7. Fold and wrap the completed request form around the outside of the metal container and place both into outer mailing tube. Tighten screw cap firmly. Mail PROMPTLY and unrefrigerated via the U. S. Postal Service (USPS) First Class Mail to the laboratory. 8. The maximum in-laboratory turn-around time for Parasitology specimens is 6 working days. The usual examination time is 1-2 working days after receipt. The submitter should allow sufficient transit time for the USPS to deliver results. Results will be sent as photocopies of the original report.