Free INDIANA STATE DEPARTMENT OF HEATLH - Indiana

MYCOLOGY TEST REQUEST
State Form 6983 (R6/10-07) CLIA Certified Laboratory #15D0662599

Date Received________________

ISDH Lab Number_______________

Reset Form
Indiana State Department of Health Laboratories 550 W. 16th Street, Suite B Indianapolis, IN 46202-2203 (317) 921-5500 Patient Last Name* First Name * M Age Sex

SEND REPORT TO:

Specimen Information Culture for Identification Date Submitted________________________________ Source________________________________ Media________________________________ Suspected Organism ________________________________ Specimen/Sample Date Collected________________________________ Date Submitted________________________________ Type________________________________

Contact Person: ____________________________________ Phone Number: ( )_______________________________ Ext.______

INITIAL REPORT Date __________________ By___________ Gram Stain Negative Gram Stain Positive for Fungal Forms Specimen cultured; allow 2-4 weeks or longer Culture received; identification in progress
PROGRESS REPORT Date___________ By_____________

FINAL REPORT Date___________________ By___________ Fungus not Isolated Specimen/Culture Unsatisfactory Organism(s) Isolated/Identified: Identified by Exoantigen Test Identified by GenProbe
FINAL IDENTIFICATION

Copy to Chronic and Communicable Disease

MYCOLOGY (Examination for Fungi) INSTRUCTIONS
Fill out the request form as completely as possible. TYPE OR PRINT LEGIBLY. The report will be photocopy of the front side only, returned in a window envelope to the address you transcribe in the "Send Report To" box. Submission of Cultures ­ PROVIDE OWN APPROVED MAILING CONTAINER 1. Submit a pure culture on an agar slant. Use a screw-capped tube only. PETRI DISH OR BROTH CULTURE SUBMISSIONS ARE UNSATISFACTORY AND WILL BE DISCARDED UPON RECEIPT. 2. Pack the culture in the container assuring that all lids are securely tightened. Enclose the specimen and this completed form in approved packaging conforming to postal laws for shipping cultures and mail to the laboratory. 3. Specimens without a patient name or ID will be considered UNSATISFACTORY and may not be tested.

*REQUIRED INFORMATION