LABORATORY INFORMATION
PATIENT INFORMATION
SPECIMEN INFORMATION
SUSCEPTIBILITY RESULTS – Please attach a copy of your susceptibility results or list the susceptibility interpretations below.
Submitting laboratory:
NHI number:
Client laboratory number:
Interpretive standard (tick one): EUCAST CLSI
Date specimen collected:
Surname:
Sample site: Other (please specify):Blood:
SNAP study number:
Forenames:
Gender:
Ward: Healthcare facility:
Date of birth:
District Health Board:
Date received at ESR:
LABORATORY SERVICES REQUEST FORM
STAPHYLOCOCCUS AUREUS (FROM BLOOD)
REFERRAL FORM
INSTRUCTIONS FOR USING THIS FILLABLE FORM:
In Acrobat Reader DC, please complete this form, then ‘SAVE AS PDF’ to your hard drive. Email your form to NIL@esr.cri.nz and print a
copy t
o accompany your sample. Forward the form with the isolate to the Nosocomial Infections Laboratory, ESR, Kenepuru Science
Centre, 34 Kenepuru Drive, Porirua 5022.
ESR0909
vers 1.0 DEC 2020
www.esr.cri.nz
RESET FORM
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
Interpretation – please tick applicable
Cefoxitin S I R
Ciprooxacin S I R
Clindamycin S I R
Co-trimoxazole S I R
Daptomycin S I R
Doxcycline S I R
Erythromycin S I R
Fusidic Acid S I R
Gentamicin S I R
Linezolid S I R
Mupirocin S I R
Oxacillin S I R
Quinupristin/Dalfopristin S I R
Rifampicin S I R
Teicoplanin S I R
Tetracycline S I R
Vancomycin S I R MIC
Comments, if required
mg/L
