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 identication 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):
Identication
RNA/DNA detection (specify):
Typing (specify):
Antimicrobial susceptibility (specify):
Toxin detection (specify):
Other (specify):
REASON FOR REFERRING SPECIMEN
For reference Conrmatory 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 identication
Sample type:
Body site:
Site modier:
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
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