Free 09356.pdf - Indiana

PERTUSSIS DFA AND CULTURE
State Form 9356 (R3/10-07) CLIA Certified Laboratory #15D0662599

Reset Form
PLEASE TYPE OR PRINT LEGIBLY

INDIANA STATE DEPARTMENT OF HEALTH LABORATORIES th 550 W. 16 STREET, SUITE B Indianapolis, IN 46202-2203 (317) 921-5500

REQUIRED PATIENT INFORMATION
Name (Last) Address City IN Attending Physician Address Zip Code (First) Age Sex Address City

Name and Address to mail Report To:
Facility Name

Zip Code IN

Contact Person Phone Number ( ) Fax Number ( )

REQUIRED SPECIMEN INFORMATION
Date Collected: Was the tube incubated prior to shipment? Yes hours No Date Of Onset: Antimicrobial Therapy Begun: Yes No Pertussis Vaccination: Yes No Nasopharyngeal (Preferred): Yes Other (please specify): Comments:

COMUNICABLE DISEASE STATISTICS
If Yes, indicate drug: Dates: Date Started: Date Ended:

DO NOT WRITE BELOW THESE LINES LABORATORY REPORT
PRELIMINARY REPORT: FINAL REPORT:

Date: DFA test NEGATIVE Bordetella pertussis Bordetella parapertussis Test Results for Bordetella: NEGATIVE POSITIVE DFA Culture NO GROWTH Bordetella parapertussis

Bordetella pertussis DFA test POSITIVE Bordetella pertussis Bordetella parapertussis Unsatisfactory Comments

Further studies in progress; final report will follow

Lab Number: Date of Final Report:

Date Received:

Copy to EPI Resource Center PLEASE READ INSTRUCTIONS (on back of form) BEFORE COLLECTING THE SPECIMEN

INSTRUCTIONS
Fill out completely the upper half of the request form on the reverse side. TYPE OR PRINT CLEARLY. The report will be a photocopy returned in a window envelope to the "Name and Address for Report" the patient's physician or other appropriate medical official.

SPECIMEN COLLECTION AND TRANSPORT:
1. To take the specimen, immobilize the patient's head and gently pass the swab through the nostril into the nasopharynx.

IT IS NECESSARY TO OBTAIN TWO SPECIMENS FOR EACH PATIENT (USE ONE SWAB FOR EACH SIDE) RATHER THAN A SINGLE ONE
2. Once the specimens have been taken, prepare 4 smears (2 SEPARATE SLIDES) by rolling the swab to cover the entire circle. Use frosted end of the slide to make smears. Label the slides with patient name.

ROLL SWAB TO MAKE SMEAR ON SLIDE
3. Place the swabs in the tube containing the semisolid transport media. Be sure to immerse the swab completely in the media. SNIP WIRE, and re-cap tightly. Label the tube with patient name and collection date.

LEAVE SWAB IMMERSED IN THE MEDIA FOR TRANSPORT
4. AIR-DRY the prepared slides. Replace dry smears in plastic slide holder (2 per holder). When ready to ship, place the slide holder and the inoculated transport media into the metal container and secure the screw cap tightly. Fold the completed patient submission form in half (bottom and top) and roll it around the metal container. Insert that into the outer cardboard container and securely tighten the screw cap before mailing. 5. It is RECOMMENDED to send the specimen to the laboratory 24 hour-next day delivery. It will insure expedited transport, faster DFA results, and better recovery. If unable to do so, then incubate the inoculated transport media tube at 35ºC or hold refrigerated until ready to mail. Record this information on the front of the form within the comments area of specimen collection.
6. THE NAME OF THE PATIENT AND THE COLLECTION DATE ARE REQUIRED ON SLIDES (SMEARS

SIDE), SLIDE HOLDER AND TRANSPORT MEDIA TUBE. WITHOUT THIS INFORMATION THE SPECIMEN WILL BE CONSIDERED UNSATISFACTORY AND MAY NOT BE TESTED. Be sure to give complete patient information including immunization records and antibiotic therapy.
7. DO NOT USE TRANSPORT MEDIA TUBE IF EXPIRED, BROKEN OR CONTAMINATED. 8. The ISDH will reserve the right to refuse and /or discard any specimen(s) received in an inadequate or

unsafe container.