Fillable CLINICAL TEST REQUISITION STATE OF CONNECTICUT DENOTES REQUIRED (State of Connecticut/Department of Administrative Services)

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CLINICAL TEST REQUISITION STATE OF CONNECTICUT DENOTES REQUIRED (State of Connecticut/Department of Administrative Services)

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CLINICAL TEST REQUISITION
STATE OF CONNECTICUT
Dr. Katherine A. Kelley State Public Health Laboratory
395 West Street, Rocky Hill, CT 06067
CLIA ID 07D0644555 / CT License CL-0197
Phone 860-920-6500
CLIENT SERVICES 860-920-6635
Submitter Facility Name/Address
DENOTES REQUIRED INFORMATION
Section 1: Patient Information (Please Print Clearly)
Name (Last, First, M.I.) or Identifier:
Street Address:
City, State, Zip:
Date of Birth:
Gender: Female Male Unknown
Home Phone:
Race (check all that apply): ( Race/Ethnicity Information is Required for Blood Lead)
White Black/African Amer. Asian Amer. Indian/Alaska Nat. Nat. Hawaiian/Other Pacific Islander Other Unknown
Ethnicity: Hispanic Non-Hispanic Unknown
Ordering Healthcare Provider: Phone:
Section 2: Specimen Information
Specimen Storage (Prior to Delivery): Refrigerated (2-8
°
C) Frozen (<-20
°
C) Ambient Temperature
Specimen Transport/Delivery: Cold (Ice pack) Frozen (Dry Ice) Ambient Temperature
Date Collected:
Time Collected: AM PM
Specimen Source/Type:
 Blood (whole) Bronchial Wash Buccal cavity Cervix CSF Nasopharynx Oropharynx Plasma
Rectal Serum Sputum Stool Urethra Urine Vaginal
Body Fluid, specify ____________________________________ Tissue, specify ________________________________________
Other, specify
Section 3: Select Testing Requested
Bacteriology
Virology
AFB Clinical Specimen (Mycobacteria Smear & Culture)
AFB Referred Culture (Mycobacteria for Identification)
Bioterrorism Agent Identification
specify agent:____________________________________
Bordetella pertussis (DFA, Culture) (DNA amplification)
Chlamydia/ Gonorrhea Nucleic Acid Amplification Test
CRE panel Organism:_________________________________
EIP Isolates for Identification (Check one)
Group A Streptococcus H. influenzae L. monocytogenes
N. meningitidis S. pneumoniae Other: ___________________
Enteric Isolate for Identification
Campylobacter E. coli O157 Salmonella Shigella
Shiga-toxin producing E. coli Vibrio Other: _________________
Enteric (Stool) Culture CIDT Organism: ___________________
Shiga-toxin (+) Broth Culture
Arbovirus IgG/IgM (Encephalitis Viruses)
California Group, Eastern Equine, St. Louis, Western Equine
Hepatitis B Surface Antibody
Hepatitis B Surface Antigen
Hepatitis C Testing
Herpes Simplex IgG Antibody
Herpes Simplex DNA amplification
HIV-1/HIV-2 Ag/Ab
HIV Viral Load
Influenza PCR
Measles PCR
MERS CoV (Novel Coronavirus) (Epidemiology Approval Required)
Mumps PCR
Norovirus PCR (Epidemiology Approval Required)
Respiratory Virus Antigen Panel: Adenovirus, Human
Metapneumovirus, Parainfluenza, Rhinovirus/Enterovirus, RSV
Varicella Zoster IgG Antibody
West Nile Virus IgM Antibody
Virus Identification (Tissue Culture)
NOTE: Zika virus testing requires submission of the
Zika Virus Clinical Test Requisition
Bacterial Serology
QuantiFeron-TB Test (Specify Date & Time Collected Above)
Syphilis Screen (VDRL)
Syphilis Confirmation (VDRL & TP-PA)
Syphilis CSF (VDRL Only)
Blood Lead (Uninsured Patients ONLY)  Race/Ethnicity Required
Child Lead Screen (Capillary Blood)
Lead Confirmation (Venous Blood)
Test, Agent or Disease, Not Listed (Specify)
Mycology
Candida auris identification
Comments
Parasitology
Blood Parasite - Smear
Form OL-9B Rev. 9/17/2019
ACCESSION LABEL
FOR CTDPH
LABORATORY USE ONLY
LAB PROFILE Number:
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CLINICAL TEST REQUISITION STATE OF CONNECTICUT DENOTES REQUIRED (State of ConnecticutDepartment of Administrative Services)

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Completed 31 March 2021

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