www.esr.cri.nz
INSTITUTE OF ENVIRONMENTAL SCIENCE AND RESEARCH LIMITED
Kenepuru Science Centre: 34 Kenepuru Drive, Kenepuru, Porirua 5022 | PO Box 50348, Porirua 5240, New Zealand
T: +64 4 914 0700 F: +64 4 914 0770
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
SINGLE SPECIMEN REQUEST – FOR SPECIMENS
OF NON HUMAN ORIGIN
SOURCE INFORMATION ESR USE ONLY
Comments:
Address / locality:
ID:
Animal:
Poultry (specify):
Environment (specify):
Water (specify):
(include temperature of water when sampled if relevant)
Shellsh (specify):
Food (specify): Raw Cooked Frozen Local Imported
Other (specify):
Attach
label here
SPECIMEN INFORMATION
Your laboratory number assists specimen identication
Date collected:
Time collected: am pm
Origin of specimen:
Isolate submitted as:
Collection site:
Location:
Sampled by:
Laboratory number: Date sent to ESR:
TEST REQUIRED Routine URGENT
Antimicrobial susceptibility (specify):
Isolation (specify):
Identication
Molecular typing (specify):
RNA / DNA detection (specify):
Serology (specify disease markers):
Serotyping
Toxin detection (specify):
Whole genome sequencing
Other (specify):
REASON FOR INVESTIGATION
For reference conrmatory test (please provide your laboratory results)
For surveillance / formal survey
From outbreak from carrier from contact
Other (specify):
Senders order number:
Case number (if known):
ESR0766
vers 4.0 MARCH 2020
ESR USE ONLY
Ambient Chilled Frozen
Received: A R
RELEVANT LABORATORY RESULTS
Your results help us to manage the tests carried out.
DETAILS FOR REPORTING
Contact:
Phone:
Email:
Lab/Org name:
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:
Kenepuru Science Centre: 34 Kenepuru Drive, Porirua
NCBID – Wallaceville: 66 Ward Street, Upper Hutt
for ________ days
for ________ months
INSTRUCTIONS FOR USING FILLABLE FORMS: In Acrobat Reader,
please complete this form, then ‘SAVE AS PDF’ to your hard drive.
Email to specimen.reception@esr.cri.nz Print out your form and
send to ESR with your specimen.
RESET FORM
