Free 13701.pdf - Indiana

MYCOBACTERIOLOGY TEST REQUEST
State Form 13701 (R8 / 6-09)

CLIA Certified Laboratory #15D0662599

INDIANA STATE DEPARTMENT OF HEALTH LABORATORIES TH 550 W. 16 STREET, SUITE B INDIANAPOLIS, IN 46202 (317) 921-5892

Section 1. Patient Demographics
Patient ID Number________________________________

_______________________________ ________________________
Last Name First Name

_______ ___/___/______
MI Date of Birth

Male

Female

____________________________________
Street Address (number and street)

______________________________
City / County of Residence

____________ _________
State ZIP Code

___________________________________
Patient Clinic ID

Section 2. Physician Information ___________________________________
Physician Last Name

__________________________________
First Name

___________________________________
Street Address (number and street)

_______________________________ ____________ _________
City / County of Residence State ZIP Code

Section 3. Specimen Information
Sample type (CHECK ONE) Specimen Isolate

Specimen Source: Sputum

Bronchial

Other specimen source list here_______________________________________________

Date of Collection _________/_________/_________

Time of Collection __________________________

Anti-Mycobacterial Therapy:

None

ISO

ETH

STR

RIF

PZA

Other

List other drug therapy here___________________________________________________________

Section 4. Submitter Information
Provider Code: ____________________________________ Staff ID________________________________________________

_________________________________________________________ ______________________________________
Submitting Organization Staff Name

_______________________________ _______________________________ ________________________________
Telephone Fax E-mail

_________________________________________________________________________________________
Address (number and street)

_________________________________________________________________________________________
Additional address

______________________________________ _________________________ ________________
City State ZIP Code

Submitter comments_______________________________________________________________________________________________________

Section 5. Collection and Submission Instructions
A. Complete the request form. TYPE or PRINT legibly with black ink.

1. For Submission of Clinical Specimens use the ISDH Container No. 6A ­ Tuberculosis

2. WRITE THE PATIENT NAME AND COLLECTION DATE ON THE REQUEST FORM, SPECIMEN TUBES, AND CULTURES.

3. WITHOUT THIS INFORMATION THE SPECIMEN WILL NOT BE TESTED.

Section 6. Specimen Collection
1. Collect sputum early in the morning BEFORE the patient eats or drinks. It should be raised from the lungs, not saliva, and deposited directly into the furnished plastic specimen container before shipment. 2. After collection, tighten the specimen tube cap to avoid breakage and leakage. Label clearly on the outside of specimen container with the patient name and collection date. Place the specimen containing tube in the white-plastic screw-cap container and tighten the cap securely. IF THE SPECIMEN CANNOT BE PACKAGED AND SHIPPED IMMEDIATELY, STORE REFRIGERATED AT OR NEAR 4°C. 3. After completing the patient request form, fold and then wrap the form around the white plastic container. Insert both together into the outer cardboard mailer and forward to the laboratory promptly. NOTE: If gastric washings are to be submitted, you must neutralize the washings to about pH 7 within 30 minutes after collection or the organisms will die.

Section 7. Submission of Cultures
1. Submit a pure culture on a tubed slant of mycobacterial culture medium, preferably Lowenstein ­ Jensen. 2. Pack the culture tube to prevent breakage and to conform to USPS and D.O.T. regulations for "Category A, Biological Substances". 3. Wrap the culture tube in absorbent material, place it in the inner mailing container and tighten the cap securely. The completed request form may be wrapped around the inner container and both enclosed securely in an outer shipping container. DO NOT send or deliver cultures grown on Petri plates; they will not be accepted. 4. Address and affix a mailing label to assure prompt delivery to the laboratory.

Section 8. Test Service Information
1. All samples received with completed paperwork are tested. If there is a problem with your submission you will be promptly notified by telephone, mail or both. SPECIMENS WITHOUT A PATIENT NAME OR ID WILL BE CONSIDERED UNSATISFACTORY AND WILL NOT BE TESTED. 2. Drug susceptibly testing procedures is performed on M. tuberculosis only. 3. Bactec 460 S.I.R.E testing requires approximately 1 week to complete. (This procedure is automatically performed for new patients and on patients who remain culture positive after 3 months of treatment.)