Version: Bacteriology / Parasitology 2018-1
CITY AND COUNTY OF SAN FRANCISCO
PUBLIC HEALTH LABORATORY
101 Grove Street, Room 419 THIS SPACE IS FOR LABORATORY USE ONLY
San Francisco, CA 94102
Tel: (415) 554-2800 Fax: (415) 431-0651
CLIA ID # 05D0643643 BACTERIOLOGY / PARASITOLOGY SUBMISSION FORM
(FOR MYCOBACTERIOLOGY, USE THE GENERAL REQUEST FORM)
ALL FIELDS ARE REQUIRED – PLEASE TYPE OR PRINT LEGIBLY
Patient information:
Patient’s Name: __________________________________ , _______________________________ ________
Last, First (Middle)
Gender: ________ Date of Birth: _______ / _______ / ________ Medical Record #: __________________
Patient’s Address: ___________________________________________________ Phone: __________________________
City / State: ________________________________________________________ Zip Code: ________________________
Submitting Clinic Information:
Submitting Laboratory/Clinic: ______________________________
Requesting Clinician: _____________________________________
(REQUIRED)
COLLECTION DATE: ____________________
Specimen source (check one):
□ Blood □ Urine □ Stool □ CSF
□ Wound, location: _____________________________
□ Tissue, type: ________________________________
□ Other, specify: _______________________________
□ Blood smear (for malaria): □ Thin □Thick
TEST REQUESTED:
BACTERIOLOGY
Enteric Culture for Identification / Title 17 Submission
Special Bacteriology Culture for Identification**
Carbapenemase Gene PCR (includes KPC, NDM,
IMP, VIM, and OXA48 genes)
Clearance for: _________________________
Other: ________________________________
PARASITOLOGY
Malaria PCR** (submit whole blood AND thin smears)
Clearance for: __________________________
**Additional information required below.
FOR ALL CULTURES FOR IDENTIFICATION:
Cultures made from original clinical sample were: □ Pure □ Mixed
If mixed, list other organisms present: __________________________________
Indicate colony count where applicable (e.g. urine): ______________________
Number of times organism isolated from the patient: ___________
Medium(s) on which primary growth was obtained: ______________________
Were stained smears or other preparations made directly from clinical material?
□ Yes □ No
If yes, was this organism seen? □ Yes □ No
Medium on which organism is being submitted: ___________________________
Date inoculated: _______________________
Conditions prior to mailing: Temp: ______ Atmosphere: ______ Length: _____
FOR SPECIAL BACTERIOLOGY ONLY:
Required: Brief but complete case history, therapy,
outcome (attach additional forms if necessary):
For instructions on collecting and storing specimens, along with electronic
copies of this form, please visit our website at: www.sfcdcp.org/phl.
SUBMITTER’S LABORATORY FINDINGS
FOR MALARIA ONLY (Required):
Physician’s Name: ________________________
Physician’s Phone #: ______________________
Date on onset: ___________________________
Travel history, symptoms, treatment:
Submitter’s laboratory findings (biochemical results, Gram stain results, agglutination results; please be comprehensive—attach additional forms as
necessary):
Submitter’s identification of organism:
Comments: ___________________________________________________
_________________________________________
