Free 53762.pdf - Indiana

SURVEILLANCE SEROLOGY REQUEST HIV, HEPATITIS B/C, SYPHILIS SAMPLE SUBMISSION
State Form 53762 (11-08) 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) 921-5858

SECTION 1. PATIENT DEMOGRAPHICS ____________________________________ __________________ _______ _____/_____/_____
Last Name ________________ ___________________ Patient ID OPSCAN First Name MI Date of Birth _____________________________________ _________ ___________ City / County of Residence State ZIP Code

Race: Asian Black or African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander

White Multiracial Other Unknown

Ethnicity: Hispanic or Latino Not Hispanic or Latino Unknown Sex: Male Female Unknown
Pregnant Yes No

SECTION 2. SPECIMEN INFORMATION Blood Serum Oral Fluid CSF SECTION 3. TEST SELECTION HIV Screening Hepatitis B Perinatal Hepatitis B Syphilis Screening HIV Confirmatory (For previous rapid test positive only. Date of test ___/__/___ Hepatitis C ( Immunized infant born to prenatal positive mother Household/Sexual contact) Syphilis Confirmatory Date collected ___/___/____ Date of onset ____/___/____

SECTION 4. REASON FOR TEST Refugee Screening Correctional Screening Injection Drug User Outbreak Investigation Hepatitis: Immune status ( Patient Staff Post Exposure) Recent Infection Exposure Suspected carrier Syphilis: Screening Prenatal Screening Follow-up SECTION 5. SUBMITTER INFORMATION

_____________________________________________
Submitting Organization

_

__

_____

Staff Name

__________________________ _________________________ ___________________________
Phone Fax E-mail __________________________________________________________________________________________________ Address _________________________________________________ City
HIV Label Syphilis Label

_________________ State

_________________________ ZIP Code
Hepatitis Label

SPECIMEN COLLECTION
1. Submit at least 3ml of serum in a screw-capped serum tube. Alternatively collect at least 710ml of whole blood in a red top venipuncture or serum separator tube. Label the specimen tube with patient identifier and collection date. Specimens without a patient ID or collection date will be considered unsatisfactory and will not be tested. 2. Complete all sections 1 through 5 on the reverse side of this form in ink. Patient ID and collection date must match those recorded on the specimen tube. The submitter address to which the results are to be sent including zip code, must be included, as well as the requested test type. Any incomplete information will cause significant delays in receiving results.

SPECIMEN PACKAGING AND SHIPMENT
Note: Specimens should be refrigerated at 4°C if held prior to shipping. Serum or whole blood in serum separator tubes may be shipped at ambient temperature. Shipping whole blood in red top tubes at ambient temperature may result in hemolysis and a specimen unsatisfactory for testing. 1. Use a UN3373 Biological Substance, Category B shipping container or container 1B HIV, 5B Syphilis or 11B Hepatitis, containers provided by ISDH. ISDH containers may be obtained by phoning (317) 921-5875. 2. Place documents in outer container or in plastic bag to prevent contamination from specimen. All specimens may be shipped on cold pack if possible. 3. Specimens should be shipped to arrive at ISDH Monday through Friday. Shipping specimens which will be in transit during the weekend or holiday is not recommended. 4. Complete the pre-addressed mailing label and affix to the outer mailer with a return address. Please use the above packing instructions to assure compliance with USPS and D.O.T. shipping regulations and to minimize breakage and leakage of the specimen. Broken or leaking specimens present a biohazard and cannot be tested. 5. Specimens submitted by courier should be packaged securely to prevent breakage. loose specimens in Ziploc bags increase the chance of breakage and biohazard exposure. DIRECT QUESTIONS TO: 317-921-5858