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HOSPITALIZED PATIENTS ONLY
Influenza Testing
Fee
sticker
Project #
1492
Bar Code
Sticker
(MDH Use Only)
Public Health Laboratory * 601 Robert St N * St. Paul MN 55155 * 651-201-5200
Clinical Testing and Submission Form
PATIENT INFO
FACILITY INFO
Last name:
Name:
First name:
Address:
MI:
Address:
St:
City:
City:
St:
Submitter #:
Phone:
Clinician name:
Phone:
U Person filling out form:
Phone:
Zip:
Patient ID #:
M
Gender:
DOB:
mm/dd/yyyy
F
Zip:
Patient:
location
Specimen or Isolate Source Information
Specimen
Isolate
Lab sample #:
Blood
Serum
acute
Collection date:
Plasma
Abscess:
mm/dd/yyyy
Collection time:
a.m.
p.m.
Bone:
convalescent
Bronchial:
CSF
Sputum
induced
site:
If box is checked, do NOT select any tests. MDH will determine.
site:
Urine
Wash
Aspirate
site:
Swab
Check box AND specify organism if this is a required submission per
the Reportable Disease Rule (Chapter 4605)
Biopsy
site:
Wound
expectorated
Stool
Body fluid:
Tissue
Other:
site:
Organism: click here to choose
Test Requested
MICROBIOLOGY
Bacillus anthracis *
Bacterial ID; specify:
Botulism testing *
Brucella *
C. diptheriae *
Enteric culture;
routine
specify:
Enteric pathogen ID;
specify:
Francisella tularensis *
GC culture (MDH approval only)
Haemophilus ducreyi *
Legionella culture & DFA
Pertussis culture/PCR
Yersinia pestis *
Other; specify:
*Call lab prior to sending
Submitting laboratory's
comments:
MYCOBACTERIOLOGY
Mycobacterial smear & culture
Mycobacterial ID
MYCOLOGY
Fungal ID;
specify:
PARASITOLOGY
Ova and parasite exam;
specify:
Thick and thin blood films;
VIROLOGY
SEROLOGY / IMMUNOLOGY
X Virus detection/ID*;
Arborvirus/WNV panel
HIV (MDH approved submitter only)
Measles IgM/IgG
Rubella IgM/Total Ab
Syphilis:
Screening (USR)
Confirmation (TPPA)
X
screen result:
Mumps
Rubella
Other Virus;
specify:
method:
VDRL (CSF only)
specify:
*MDH will determine testing
protocol (culture and/or PCR)
Other exam;
specify:
Parasite ID/confirmation;
specify:
Adenovirus
Enterovirus
Herpes Simplex Virus
Influenza
B
unknown
A
Measles
Hospital admitted to:
Date of admission:
Influenza result: A
pos
B
neg
Test type:
Rapid
pos
Subtype:
neg
PCR
Culture
FA
Dec 2011 v1.5