Form Il 482-1039 - Communicable Diseases Laboratory Test Requisition - Illinois Department Of Public Health
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1
2State of Illinois
Communicable Diseases
Illinois Department of Public Health
Laboratory Specimen Number
Laboratory Test Requisition
(FOR PUBLIC HEALTH USE ONLY)
Outbreak #:
Type or use indelible dark ink and print legibly with capital letters
SUBMITTER INFORMATION:
_____________________
_____________________________________________________________
Submitter Code
Submitter Name
____________________________________________________
__________________________________
_______
____________
Submitter Address (Street Number, Name of Street)
City
State
ZIP Code
_____________________________ _____________________ _____________________ ____________________________________
Contact Person/Clinician’s Last Name
Telephone Number
FAX
E-mail Address
PATIENT INFORMATION:
_________________________________________
__________________________________
________________________________
Patient’s Last Name
First Name
Middle Name
_______________________________________________________________________________
______________________________
Street Address
Apartment/Suite Number
_____________________________________________________________
______________________________
________________
City
State
ZIP Code
____________________________________
________________
____________
Telephone Number
Birthday (mm/dd/yyyy)
Age
Sex
Race
Ethnicity
Male
White
Native American
Other/Unknown
Hispanic
Female
African American/ Black
Asian/Pacific Islander
Non-Hispanic
Patient ID # (optional) ______________________________________ Medicaid Recipient ID # __________________________________
TEST REQUEST INFORMATION
When sending acute and convalescent serology specimens, use one test requisition. Complete collection information
immediately below for acute specimen and complete collection information for convalescent specimen in the “Source/Specimen Type” box.
____________________
_____:_____ (
) a.m.
____________________
Initials of Person _______
Initials of Person _______
(
) p.m.
Collecting Specimen
Completing Form
Date Collected (mm/dd/yyyy)
Time collected
Date of Onset
TEST
SOURCE/ SPECIMEN TYPE
REASON
Arbovirus Panel
MTBC – PCR
Blood - Film
Skin
Carrier
(Resp. spec. only)
B. Strep (Gp A)
Blood - Serum
Smear
Confirmation
MTB Genotyping only
B. Strep (Gp B)
Blood - Whole
Spinal Fluid
Contact
Norovirus
Bacillus anthracis
Body Fluid (Specify Below**)
Stool/Feces
Diagnosis
Orthopox virus
Brucella
Bronchial Washing
Sputum
Foodborne Illness
Pertussis PCR
Burkholderia
Fecal Swab
Tissue Culture Fluid
Immunity
Respiratory Panel
Cyclospora
Genital Swab
Tissue (Specify Below**)
Outbreak
Salmonella
Cryptosporidium
Nasal Aspirate
Throat Swab
Post Vaccination
Shigella
E. coli
Nasopharyngeal Swab
Urine
Routine Screening
Staphylococcus aureus
Francisella
O&P Kit
Vaginal Swab
Rule Out Threat Agent
Varicella-zoster
Gonorrhea Culture
Pharyngeal Swab
Other (Specify Below**)
Symptomatic
Yersinia
Giardia
Rectal Swab
Other Swab
Treatment
Yersinia pestis
(Specify Below**)
Malaria
Referred/Isolated Culture
Typing
Vibrio
Measles PCR
Serum – Acute
Quarantine Release
Other (Specify Below*)
Mumps PCR
Serum - Convalescent
Other (Specify Below***)
MTBC Smear, Cult,
Date Collected ________________
ID & Sens
Initials of Collector ___________
_______________________________________________________
_______________________________________________________
*OTHER TEST
**SOURCE
________________________________________________________________________________________________________________________
***REASON(S)
OVER- For Referred Cultures and Instructions
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