www.esr.cri.nz
ESR LABORATORY SERVICES REQUEST FORM
REQUEST FORM FOR USE BY PUBLIC HEALTH STAFF
FOR THE REFERRAL OF CLINICAL SPECIMENS FOR
MICROBIOLOGICAL ANALYSIS
RESET FORM
Date tested: Laboratory number: Laboratory number:
ESR USE ONLY
Date specimen received:
INSTRUCTIONS FOR USING FILLABLE FORMS: In Acrobat
Reader, please complete this form, then save the pdf to your
hard drive. Email this form to
ncbid.erl@esr.cri.nz then print it
out and attach to your submitted specimen.
ESR0561
vers 2.0 MAR 2018
Using Acrobat Reader DC, SAVE AS pdf with a new name and email this request form to: ncbid.erl@esr.cri.nz
INFORMATION TO SUPPORT ANALYSIS Please provide the following information for suspected food poisoning investigations
Incubation time: Symptoms:
Other details:
Any related food samples being analysed? Yes No
If yes, please provide HPO reference numbers of samples:
PATIENT INFORMATION
Patient surname:
NHI Number (if applicable):
EPISURV Number (if applicable):
Given names:
Date of birth: Sex: Male Female
TESTS REQUIRED Please tick
Suspected food poisoning complaints – Food poisoning investigation
Others (please specify):
For clearance of notiable infectious gastrointestinal disease Typhi/Paratyphi Shigella VTEC
TYPE OF SPECIMEN
Faeces Rectal swab Other (describe):
Collection date:
Collection time:
INFORMATION FOR CLEARANCE/CONTACT TRACING OF NOTIFIABLE INFECTIOUS GASTROINTESTINAL DISEASE
Case/contact First specimen
Clearance specimen
High risk
Group 1 1st specimen 2nd specimen 3rd specimen
Group 2 1st specimen 2nd specimen 3rd specimen
Group 3 1st specimen 2nd specimen 3rd specimen
Group 4 1st specimen 2nd specimen 3rd specimen
ADDRESS FOR REPORTS
Address Send copies of report to:
Email: Phone: Phone:Email:
ESR USE ONLY – CONDITION OF SPECIMEN
Watery
Comments:
Soft
Mucous Bloody Other (specify)Well formed
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
PLEASE NOTE: Saturday receipt is by prior arrangement only
The information contained in this form will only be be used for the purpose for which it is collected and will otherwise be kept strictly condential
Health Protection Ofcer name:
Project identier number: HPO reference number:
Refer Appendix
2 Communicable
Disease Control
Manual Dec 2017
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