Test Requisition - State of Michigan …

1 State OF Michigan - LABORATORY TEST REQUISITIONM icrobiology / VirologyDCH - 0583 May 02, 2016By Authority of Act 368, 1978 AGENCY CODE (If Known) FPTELEPHONE STDFAXCONTACT PERSON/ORDERING PHYSICIAN/PROVIDER NAMENATIONAL PROVIDER IDENTIFIER #NAME (LAST, FIRST, MIDDLE INITIAL) or UNIQUE IDENTIFIERSUBMITTER PATIENT # (If Applicable)CITYZIPGENDERRACE MALE FEMALE Asian White ETHNICITYADAP NUMBERBIRTH DATE (MM-DD-YYYY) SUBMITTER SPECIMEN #COLLECTION DATE (MM-DD-YY) May-Oct Includes: Eastern Equine, California, St. Louis and West NileCSF Only SYPHILIS IgM WESTERN BLOT* (1)HEPATITIS A ANTIBODY (IgM) (1)* Prior Approval RequiredHIV-1 VIRAL LOAD (EDTA plasma) (1)SYPHILIS FTA - ABS DS* (1)VIRAL CULTURE (HBsAg) (1)HIV-1 GENOTYPING (EDTA plasma) (1)SYPHILIS TP-PA* (1)HEPATITIS B ANTIBODY (Anti-HBsAg) (1)HIV Ag/Ab-Oral Mucosal Transudate (1)SYPHILIS VDRL - CSF Only (1)RESPIRATORY PCR PANELHEPATITIS C ANTIBODY (1)CD4/CD8 (EDTA whole blood) (1)SYPHILIS DFA (1,2)INFLUENZA (PCR/CULTURE) (7)HEPATITIS B SURFACE ANTIGENHIV TESTINGSYPHILIS TESTINGVIROLOGYLYME DISEASE - DFA (Tick)

2 HEPATITIS TESTINGHIV Ag/Ab - Serum (1)SYPHILIS (USR Test) (1)ENTEROVIRUS PCR (6)FOOD-Specify:TETANUS TOXIN EIASHIGELLA SEROTYPINGAUTOCLAVE TEST STRIPSOTHER-Specify:VARICELLA ZOSTER IgGLEGIONELLA - DFAURINERABIES AB SEROLOGY (3)PERTUSSIS PCROTHERWHOLE BLOODRUBELLA IgGSALMONELLA SEROTYPING - HUMANTHROATMEASLES IgGPARASITOLOGY - STOOLTOXIC SHOCK TESTINGURETHRAMUMPS IgGPARASITOLOGY - WORMOTHER _____STOOLLEGIONELLA - HANEISSERIA - REFERRED CULTURERUBELLA IgM (1)SPUTUMLYME DISEASE - EIA (4)PARASITOLOGY - BLOODSALMONELLA SEROTYPING NON-HUMANPLASMAFUNGAL IMMUNODIFFUSIONLEGIONELLA CULTURENOROVIRUS PCR (6)SERUMFRANCISELLA SEROLOGYNEISSERIA GONORRHOEAE - ISOLATIONPERTUSSIS CULTURENASOPHARYNGEALBRUCELLA SEROLOGYFOODBORNE ILLNESS-Stool or Food (6)

3 MUMPS - PCRORAL MUCOSAL TRANSUDATEFUNGAL SEROLOGY COMPLEMENT FIXFUNGAL identification - ISOLATE IDMEASLES IgMCSFE. COLI (SLT) TOXIN & SEROLOGYEMERGING ARBOVIRUS PANELGASTRICENTERIC bacterial CULTUREPCRSEROLOGYBRONCHIALACUTECONVALES CENTAFB SLIDE/CULTURE-CLINICAL SPECIMENBACTERIAL TYPING-PFGE (6)CERVIXARBOVIRUS ENCEP PANEL (IgM)AFB identification -ISOLATE IDBOTULISM TOXININDICATE SPECIMEN SOURCESEROLOGYMICROBIOLOGYTESTS THAT REQUIRE MDHHS APPROVALAMNIOTIC FLUIDSERUM STATUS - If ApplicableAEROBIC ISOLATE ID (5)AFB NUCLEIC ACID AMPLIFICATIONH ispanic or LatinoNot Hispanic or LatinoUnknownCOLLECTION TIME (MILITARY)INDICATE TEST REQUESTEDINSTRUCTIONS FOR COMPLETION.

4 Complete reverse side of form for corresponding numbers in parentheses and in INFORMATIONSUBMITTER INFORMATION (PRINTED, TYPED OR STAMPED)PATIENT INFORMATIONA merican Indian or Alaska NativeBlack or African AmericanNative Hawaiian or other Pacific IslanderOtherDATE RECEIVED IN LABORATORYLABORATORY SAMPLE NUMBERM ichigan Department of Health and Human Services - Bureau of Laboratories Box 30035 3350 North Martin Luther King Jr. Blvd. Lansing, MI 48909 Laboratory Records: 517-335-8059 Technical Information: 517-335-8067 Fax: 517-335-9871 Web: OF Michigan - LABORATORY TEST REQUISITIONM icrobiology / VirologyDCH - 0583 May 02, 2016By Authority of Act 368, 1978 INDICATE TEST REASON Diagnosis Surveillance Outbreak (Complete Section 6) Other (Specify)(1)HIV, SYPHILIS, HEPATITIS, RUBELLA IgM REQUESTSPREGNANT?

5 FOR HEPATITIS B SURFACE ANTIGEN (HBsAg) ONLY YES NO Exposure to someone with Hepatitis B?(2)SYPHILIS DFA REQUESTSDURATION OF LESIONSPECIFIC SITE: Days Months Years(3)RABIES ANTIBODY SEROLOGY REQUESTSDATE (MM-DD-YY)DATE OF LAST RABIES VACCINATION(4)LYME BORRELIOSIS REQUESTSONSET DATE (MM-DD-YY)_____EARLY DISEASELATE DISEASE Neurologic Cardiologic Rheumatologic(5)AEROBIC CULTURE REQUESTSGRAM Aerobe Microaerophile Positive Negative Variable Rod Coccus DiplococcusMacConkeyOxidaseCatalaseDextr ose Positive Negative Positive Negative Positive Negative Oxidation Fermentation(6)OUTBREAK INVESTIGATIONONSET DATE (MM-DD-YY)OUTBREAK IDENTIFIERORGANISM SUSPECTED (If Applicable)MDHHS PRIOR APPROVAL.

6 Name, Date(7)INFLUENZA TESTING (PCR / CULTURE) REQUESTSDATE (MM-DD-YY)TYPE Flu Mist Trivalent (Shot) Other(8)ADDITIONAL INFORMATIONCOMPLETE THIS SECTION FOR: State /County/Country of Exposure:LAST INFLUENZA VACCINATION:COMPLETE THIS SECTION FOR:COMPLETE THIS SECTION FOR:COMPLETE THIS SECTION FOR:COMPLETE THIS SECTION FOR:COMPLETE THIS SECTION FOR:COMPLETE THIS SECTION FOR:Erythema Migrans (5 cm at least in diameter) bacterial GROWTH CHARACTERISTICS: OTHER:Symptoms (Example- Rash, Fever, Headache, Joint Pain)