www.esr.cri.nz
INSTITUTE OF ENVIRONMENTAL SCIENCE AND RESEARCH LIMITED
NCBID – Wallaceville: 66 Ward Street, Wallaceville, Upper Hutt 5018 | PO Box 40158, Upper Hutt 5140, New Zealand
T: +64 4 529 0600 F: +64 4 529 0633
LABORATORY SERVICES REQUEST FORM
SARS-COV-2 TO EXCLUDE COVID-19
INFECTION TEST REQUEST
PATIENT / SOURCE INFORMATION
CLINICAL INFORMATION
Please select appropriate responses and provide relevant information
Foreign travel in last 14 days (specify country):
Vaccinated with current season’s Flu vaccine:
Does the patient have an underlying condition?
ESR USE ONLY
Ambient Chilled Frozen
Received: A R
Contact with known case: Yes No If yes, specify country if not New Zealand:
NHI:
Onset date:
DHB:
Ward: Requestor:
Symptoms/Other details: (eg: Asymptomatic, pregnant including gestation)
Please tick this box if your clinical sample is post mortem
Occupation:
Date of birth: Age:
Surname:
First name:
ESR USE ONLY
Attach
label here
SPECIMEN STORAGE / TRANSPORT HISTORY
Please indicate the specimen storage condition and transportation prior to
sending to ESR
Ambient Chilled Frozen Time
Stored: for ________
Transported:
Sample sent to ESR, NCBID:
66 Ward Street, Wallaceville, Upper Hutt 5018
Sex:
Ethnicity: Lab ref no:
RESET FORM
INSTRUCTIONS FOR USING
FILLABLE FORMS:
In Acrobat Reader DC,
please complete this form,
then ‘SAVE AS PDF’ to your
hard drive. Email to
virology@esr.cri.nz
Print out your form and
send to ESR with your
specimen.
All samples submitted should be treated as though
the patient is infected with Hazard Group 3 pathogen
and you must contact the reference Lab before
sending samples to ESR, NCBID.
All samples must be shipped by Category B UN3373
ESR0793
vers4.0 March 2020
DETAILS FOR REPORTING
Contact:
Phone:
Email:
Comments:
Lab/Org name:
Date collected:
Sample type:
Date sent to lab:
SPECIMEN INFORMATION
TS NS NS/TS BAL Sputum ETS
Other specimen type (specify):
ADDITIONAL COMMENTS – IF REQUIRED
REQUESTOR’S LABORATORY RESULTS
Flu A: Yes No
H3 H1 (pdm09)
Flu B: Yes No
Other seasonal resp
(please specify)
Other pathogens
(please specify)
Diagnostic test(s) used
(give CTs)
Yes No Unknown
Immune compromised
Other
(please specify)
Please send an email to virology@esr.cri.nz of this request
form with details of transport and ETA. Also make sure this
request form is not in the bio-bottle itself but inside the box.
Courier samples to: ESR, NCBID, 66 Ward Street,
Wallaceville, Upper Hutt 5018
