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 4 913 9609
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 0633
LABORATORY SERVICES REQUEST FORM
SINGLE HUMAN SOURCE SPECIMEN
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
ESR USE ONLY
Comments:
Foreign travel (specify country):
ESR USE ONLY
Ambient Chilled Frozen
Received: A R
Animal contact: NZ Overseas If yes, specify animal contact:
NHI:
Onset date:
RELEVANT LABORATORY RESULTS
Your results help us to manage the tests carried out.
DHB:
H/C facility:
Ward: Requestor:
Symptoms/Other details: (eg: Asymptomatic, pregnant including gestation)
Occupation:
DoB:
Surname: First name:
Attach
label here
SPECIMEN STORAGE / TRANSPORT HISTORY
This section must be completed to comply with IANZ standards
Ambient Chilled Frozen Time
Stored: for ________ hours
Transported:
Sample sent to: Please TICK site you are sending your sample[s] to
Kenepuru Science Centre NCBID – Wallaceville
Sex:
Ethnicity:
RESET FORM
INSTRUCTIONS FOR USING FILLABLE FORMS:
In Acrobat Reader DC, 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.
ESR0039
vers 6.0 FEBRUARY 2016
DETAILS FOR REPORTING
Contact:
Phone:
Email:
Lab/Org name:
TEST REQUIRED Routine URGENT
Isolation/detection (specify):
Serology (specify disease markers):
Identication
RNA/DNA detection (specify):
Typing (specify):
Antimicrobial susceptibility (specify):
Toxin detection (specify):
Other (specify):
REASON FOR REFERRING SPECIMEN
For reference Conrmatory test (please provide your laboratory results)
For surveillance/formal survey For clearance
From outbreak Outbreak number:
Other (specify):
ORIGINAL SPECIMEN INFORMATION
Your laboratory number assists specimen identication
Sample type:
Body site:
Site modier:
Lab No: Date collected:
Sample source:
SPECIMEN SUBMITTED TO ESR
Organism(s) submitted:
Plasma Whole blood ACD EDTA Heparin SST
(choose one)
Serum
Acute serum
Convalescent serum
Aspirate Biopsy CSF Faeces
Sputum Swab Tissue Urine
Culture submitted as: Pure growth Mixed growth
(choose one)
Other (specify):
Date sent to ESR:
Nucleic acid
