Fillable Coronavirus Disease 2019 (COVID-19) CLINICAL TEST REQUISITION STATE (State of Connecticut/Department of Administrative Services)

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Coronavirus Disease 2019 (COVID-19) CLINICAL TEST REQUISITION STATE (State of Connecticut/Department of Administrative Services)

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Coronavirus Disease 2019 (COVID-19) CLINICAL TEST REQUISITION
STATE OF CONNECTICUT
Dr. Katherine A. Kelley State Public Health Laboratory
⧫Name/Address of Submitting Facility 395 West Street, Rocky Hill, CT 06067
CLIA ID 07D0644555 / CT License CL-0197
Phone 860-920-6500
⧫ DENOTES REQUIRED INFORMATION
In order to submit specimens for testing to the CT State Public Health Laboratory, patients must be in one of the following
categories: (Please specify)
Potential Vaccine Breakthrough Case: Case onset > 14 days past last dose of COVID-19 vaccine regimen.
Reside or work in a congregate setting.
Ver 3.6 03/23/2021
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
Section 2: Specimen Information
Submitter Sample ID:
⧫Date Collected:
⧫Specimen Source/Type:
Bronchoalveolar lavage/ wash Tracheal aspirates Sputum Nasopharyngeal (NP) Recommended
⧫Specimen Storage (Prior to Delivery):
Refrigerated (2-8
o
C)
⧫Specimen Transport/Delivery: Cold (Ice pack)
Frozen (<-20
o
C)
Frozen (Dry Ice)
For questions regarding specimen handling please call the Advances Molecular Diagnostics laboratory of the CT SPHL at 860-920-6689
Ordering Healthcare Provider Name and Address:
Phone:
Fax:
⧫Section 3: SARS-CoV-2 VIRUS TESTING
This specimen submitted for SARS-CoV-2 rRT-PC
R testing
For Laboratory Use Only
Comments
ACCESSION LABEL
FOR CT SPHL
USE ONLY
LAB PROFILE #:
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Coronavirus Disease 2019 (COVID-19) CLINICAL TEST REQUISITION STATE (State of ConnecticutDepartment of Administrative Services)

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Completed 31 March 2021

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