Fillable Alere HIV-1/2 Determine Test Log (Kansas Department of Health and Environment)

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Alere HIV-1/2 Determine Test Log (Kansas Department of Health and Environment)

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Country of origin: US
File type: PDF

U.S.A. forms for Kansas Department of Health and Environment

BROWSE KANSAS DEPARTMENT OF HEALTH AND ENVIRONMENT (KS) FORMS

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Alere HIV-1/2 Determine Test Log
Agency Name /Facility ID: _____________________________________________________
Lot # Lot Expiration Date Date Lot Placed In Use
KDHE Universal Lab
Requisition Number
Client
Date of Birth
B
R
O
C √
H
U
R
E
Specimen
Collection
Test Result
(Circle One)
C
O O
N K
T
R (√)
O
L
Time
Reported
to Patient
Counselor
Number
Preliminary Positive
Date Time
BIS
Notified
LTC
Notified
Non-reactive - Reactive
Invalid
Non-reactive - Reactive
Invalid
Non-reactive - Reactive
Invalid
Non-reactive - Reactive
Invalid
Non-reactive - Reactive
Invalid
Non-reactive - Reactive
Invalid
Non-reactive - Reactive
Invalid
Non-reactive - Reactive
Invalid
Non-reactive - Reactive
Invalid
Non-reactive - Reactive
Invalid
Temperature: __________ Location: ___________________________
Non-Reactive
No
No
Non-Reactive
No
No
Non-Reactive
No
No
Non-Reactive
No
No
Non-Reactive
No
No
Non-Reactive
No
No
Non-Reactive
No
No
Non-Reactive
No
No
Non-Reactive
No
No
Non-Reactive
No
No
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Alere HIV-12 Determine Test Log (Kansas Department of Health and Environment)

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Completed 21 October 2021

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