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 0601
LABORATORY SERVICES REQUEST FORM
INFLUENZA SURVEILLANCE – SPECIMEN
REQUEST FORM
ESR USE ONLY
Comments:
ESR USE ONLY
Ambient Chilled Frozen
Received: A R
Date collected:
SPECIMEN TYPE SITE:
Date sent to lab:
INFLUENZA VACCINATION AND ANTIVIRALS
Yes No Don’t know
Yes No Don’t know
Yes No Don’t know
Date:
Has the patient been vaccinated for inuenza in the same year as the onset
of inuenza-like illness?
Has the patient had antiviral (eg: Tamiu) medication?
Has any of the patient’s household member(s) had antiviral medication?
If known, specify date of last inuenza vaccination:
If yes, specify name, date and duration of antiviral medication:
If yes, specify name, date and duration of antiviral medication:
NAME AND ADDRESS FOR REPORTING
Contact:
Phone:
Email:
Other (specify):
Name:
Attach
label here
TESTS REQUIRED
SPECIMEN INFORMATION
Routine URGENT
SPECIMEN STORAGE /TRANSPORT HISTORY
Referring laboratories must complete this section to comply with
IANZ standards. Please indicate the specimen storage condition and
transportation prior to sending to ESR.
Ambient Chilled Frozen Time
Stored: for ________ hours
Transported:
Sample sent to:
NCBID – Wallaceville: 66 Ward Street, Upper Hutt
INSTRUCTIONS FOR USING FILLABLE FORMS: In Acrobat Reader,
please complete this form, then SAVE AS pdf to your hard drive.
Print out the form and send to ESR with your specimen.
You can email your form to virology@esr.cri.nz
ESR0040
vers 3.0 April 2015
Inuenza virus detection/subtyping by PCR
Inuenza virus antigenic strain typing/subtyping
Antiviral susceptibility
Other (specify):
Nasopharyngeal swab
Throat swab
Nasal swab
Other specimen type (specify):
PATIENT INFORMATION
CLINICAL INFORMATION
These data elds must be completed for specimen matching and identication as well as for epidemiological purposes
Please select appropriate responses and provide relevant information
Foreign travel (specify country):
Animal contact: NZ Overseas If yes, specify animal contact:
NHI number:
Onset date:
DHB: Ward: Dr/Requestor:
Symptoms/Other details:
Occupation:
DoB:
Surname: First name:
Sex:
Ethnicity:
RESET FORM
