Fillable Fairbanks ***PLEASE ALLOW 4-5 WORKING DAYS FOR SUPPLIES (State of Alaska)

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Fairbanks ***PLEASE ALLOW 4-5 WORKING DAYS FOR SUPPLIES (State of Alaska)

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Revision 11/18/2020 http://dhss.alaska.gov/dph/Labs/Documents/publications/LabSupplyRequest.pdf
Supply Request Form
Alaska State Public Health Laboratories
PHONE NUMBER:
FACILITY NAME:
MAILING ADDRESS:
ORDER DATE:
***PLEASE ALLOW 4-5 WORKING DAYS FOR SUPPLIES TO ARRIVE***
***SUPPLIES ORDERED ON SITE REQUIRE UP TO 72 HOURS TO BE FILLED***
Fairbanks
Fax order to: 907-474-4036
Obtain Fairbanks Laboratory Test Request Forms:
http://dhss.alaska.gov/dph/Labs/Documents/publications/FbxSupplyReq.pdf
QUANTITY
Anchorage
Fax order to: 907-334-2161
Obtain Anchorage Laboratory Test Request Form:
http://dhss.alaska.gov/dph/Labs/Documents/publications/AncSupplyReq.pdf
QUANTITY
TYPE
APTIMA® Urine Specimen Collection Kit for Chlamydia/Gonorrhea testing (50/box)
APTIMA® Unisex Swab Collection Kit for Chlamydia/Gonorrhea testing (50/box)
APTIMA™ Multitest Swab Specimen Collection Kit for Chlamydia/Gonorrhea testing (50/
box)
***Note: APTIMA supplies are provided to approved providers only
TB Collection tubes with sodium carbonate preservative for SPUTUM (25/bag)
TB Collection tubes WITHOUT
preservative (25/bag)
TB Blood Culture Tubes, 10 mL Wampole Isolator (SPS)
Enteric Transport Media (ETM for stool cultures)
Carey Blair Transport Swabs (isolated organisms: Campylobacter, Shigella, Salmonella, Escherichia coli
O157)
Intestinal Ova & Parasite (10% Formalin & Zinc PVA)
Universal or Viral Transport Media, UTM or VTM for virus transport. Purpose (check all that apply):
Biological substance Category B shipping container
***No additional biohazard bags are provided
Please note: Alaska State Public Health Laboratories do not provide blood collection tubes or
nasopharyngeal swabs for Pertussis PCR.
To be filled out by State lab:
Phone order taken by/date:
Order Filled by/date:
Herpes simplex
virus PCR (fees may apply)
Other testing (ex. respiratory viruses)
TYPE
Universal or Viral Transport Media, UTM or VTM for virus transport.
Purpose (check all that apply):
Insulated Serum Shippers (Required for HIV & acceptable for all serum tests)
Herpes simplex virus PCR (fees may apply)
Other testing (ex. respiratory viruses)
***NEW Validation panel for Abbott ID NOW SARS-CoV-2 testing platforms (3 specimens)
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Fairbanks ***PLEASE ALLOW 4-5 WORKING DAYS FOR SUPPLIES (State of Alaska)

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Completed 11 February 2021

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