Free 35898.pdf - Indiana

Reference Bacteriology Culture Identification
State Form 35898 (R4/10-07) CLIA Certified Laboratory #15D0662599

INDIANA STATE DEPT. OF HEALTH LABORATORIES th 550 W. 16 Street, Suite B INDIANAPOLIS, IN 46202-2203 (317) 921-5500

Mail/Fax Copy of the Report to Communicable Disease. RETURN THIS ORIGINAL FORM WITH THE SPECIMEN, NOT A COPY.

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REQUIRED PATIENT INFORMATION
Name (Last, First, Middle) Address Age Diagnosis Gender Date of Onset Physician

REQUIRED CULTURE INFORMATION
Isolation Source Date Isolated Date Submitted

EXAMINATION REQUESTED
Identification Confirmation

Organism Suspected

SUBMITTER INFORMATON
Facility Name Address City Zip Code Phone Number Fax Number

IN
Comments:

DO NOT WRITE BELOW THIS LINE

FINAL REPORT

Comments: Lab Number Date Specimen Received Date of Final Report

INSTRUCTIONS Submission of Cultures - PROVIDE OWN APPROVED MAILING CONTAINER. All mailing containers must also conform to postal and D.O.T. laws for shipping "Category A, Biological Substances". The ISDH will reserve the right to refuse and/or discard any specimen(s) received in an inadequate or unsafe container. Submit only PURE CULTURES that are to be identified. Mixed cultures will not be accepted. It is best to make submissions on low carbohydrate medium free of excess moisture. For ANAEROBES use stab cultures in a low carbohydrate medium or sealed chopped meat broth. FASTIDIOUS ORGANISMS can be sent as a heavy growth or either a blood agar or heart infusion slant. DO NOT SEND CULTURES ON PETRI PLATES Complete the top portion of this form. After packing the specimen in the inner container, wrap form around it, insert into the outer container, and affix the screw cap. 1. 2. 3. The Reference Bacteriology Section services are available to Indiana medical facilities. An effort on the part of the submitting laboratory to identify the isolate must have been made and those results made available to us upon request. Specimens without a patient name/ID will be considered unsatisfactory and may not be tested.

REFERENCE BACTERIOLOGY WORKSHEET
Date Received Date Set Up Lab Number

TEST READ DATE TEST SET DATE
GRAM RXN / MORPH. BLOOD RXN ATM. REQ. (O2 / CO2 /ANO2 / 5%O2) COLONY MORPHYLOGY MOTILITY OXIDASE CATALASE OF FERM CTA GLUCOSE XYLOSE MANNITOL LACTOSE SURCROSE MALTOSE FRUCTOSE

DATE OF OBSERVATION / INITIAL TEST READ DATE TEST SET DATE
LECITHINASE / LIPASE BILE GROWTH PY CHOPPED MEAT DIGEST THIO GEL IRON MILK CASEIN HYDROL TYROSINE HYDROL / PIGMENT TINSDALE HALO COAGULASE RABBIT PLASMA FX 100 / BA 10 / NB 5 / PB 300 DNASE / THERMONUCLEASE ONPG PYR LAP STARCH HYDROL OF FERM CTA ADONITOL AMG AMYDALIN ARABINOSE (L) CELLOBIOSE DULCITOL ERYTHRITOL GALACTOSE GLYCEROL INOSITOL INULIN MANNOSE MELEZITOSE MELIBIOSE METHY-MANNOSE RAFFINOSE RHAMNOSE RIBOSE SALICIN SORBITOL SORBOSE STARCH TREHALOSE TURANOSE XYLITOL

MAcCONKEY SS CETRIMIDE SIMM.CITRATE CHRIS. UREA NO3 REDUCTION/GAS NO2 REDUCTION/GAS INDOLE TSI SLANT/BUTT TSI H2S BUTT/PAP MR VP GELATIN HYDROL LITMUS MILK PIGMENT GROWTH 25C GROWTH 35C GROWTH 42C GROWTH C ESCULIN HYDROL LYSINE DECARB ARGININE DIHYDROL ORNITHINE DECARB NUTRIENT BR. 0% NACL NUTRIENT BR. 6% NACL THAYER MARTIN GROWTH LOEFFLER DIGEST / PIGMT AMYLOSUCRASE XV REQUIREMENT PORPHYRIN ACETAMIDE SODIUM ACETATE PROPINATE ANAEROBIC ALK. NO3 PHENYLALANINE / MALONATE BACITRACIN / OPTOCHIN BILE SOLUBILITY BILE ESCULIN 6.5% SALT TOLERANCE METHYLENE BLUE HYDROL HIPPURATE HYDROL TELLURITE / TETRAZOLIUM 6 ug VAN/ML GROWTH

Preliminary ID by GLC Analysis / Date / Initial

Final Identification / Date / Initial

(+)positive (-)negative (A)acid (K)alkaline (pep)peptonization (±)weak,slight positive (d)delayed (S)sensitive growth (R)resistant growth (IR)indicator reduced (W)weak (NG)no growth (NR)no reaction (mm)millimeter