Free Patient last name___________________________ Patient I - Indiana

SYPHILIS TEST REQUEST
State Form 13708 (R8 / 10-07) CLIA Certified Laboratory #15D0662599

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

1.

Screening

Confirmatory (Select one)

Patient Information 2. Patient I.D. Number:________________________________________________________ 3. Name:___________________________________________________________________
First M.I Last

4. Date of Birth _ _/_ _/_ _ _ _ 5. Residence: City ______________________________ State_____ Zip Code __________ 6. Sex: 7. Race: Male White Asian Other Hispanic or Latino Female Unknown

Black or African American American Indian or Alaska Native Native Hawaiian or Pacific Islander Not-Hispanic or Latino

Unknown Unknown

8. Ethnicity:

Submitter Information 9. Submitting Organization___________________________ Staff Name ________________ Phone_______________ Fax _______________ Email ___________________________ Address ________________________________________________________________ ________________________________________________________________ City ___________________________________State_____ Zip Code___________

Specimen Information 10. Collection date _ _/_ _/_ _ _ _ 11. Reason for test: Prenatal Screening Screening Follow up For Lab Use Only 12. Specimen type: Blood Serum CSF

Received Date____________________

Specimen Number

SPECIMEN COLLECTION 1. Submit at least 1ml of serum in a screw-capped serum tube. Alternatively collect at least 3.0ml 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. Complete all items 1 through 12 on the reverse side of this form in ink. Patient ID and collection date must match those recorded on specimen tube. The submitter address to which the results are to be sent including zip code must be included as well requested test type. Any incomplete information will cause significant delays in receiving results.

2.

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 container 5B provided by ISDH. 2. Wrap the absorbent material, provided in the inner mailing container, around the specimen tube to absorb inner shock and contain possible leakage. Insert the wrapped specimen tube into the inner mailing container. Secure cap tightly. Place the completed requisition between the inner and outer mailing container and secure cap. Specimens should be shipped to arrive at ISDH Monday through Friday. Shipping specimens which will be in transit during weekend or holiday is not recommended. 3. Complete the pre-addressed mailing label on the outer mailing container with a return address, leakage and breakage notification and postage, and send via first class US mail. 4. Please use the above packing instructions to assure compliance with federal shipping regulations and to minimize breakage. 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: 317-921-5500