NH PUBLIC HEALTH LABORATORIES

DEPARTMENT OF HEALTH AND HUMAN SERVICES

29 Hazen Drive, Concord, NH 03301
Telephone: 603-271-4661, Fax: 603-271-2138
CLINICAL LABORATORY TEST REQUISITION
http://www.dhhs.nh.gov/dphs/lab/documents/labrequisition.pdf Place Barcode label here

Please check if specimen is a(n): TEST LIST NOTE: Ab = Antibody Ag = Antigen

 STATE REQUESTED TEST - Approved by: __________________________________

EPIDEMIOLOGY STUDY HIV
 OUTBREAK INVESTIGATON - Outbreak Comments: _________________________ (Isolate or specimen) _ HIV Ag/Ab Combo
_ R/O Bacillus anthracis _ HIV-1/2/Group O – Screen
SUBMITTER INFORMATION - Please Print Legibly _ R/O Brucella spp (Decedent only)
_ R/O Burkholderia spp
Submitter Facility Code: ______ _ R/O Bacillus cereus MYCOBACTERIA (AFB) (TB)
Submitter Facility Name: _________________________________ _ R/O Francisella tularensis _ NAA Direct Test
_ R/O Yersinia pestis (Sputa specs only)
Address: ______________________________________________ _ Bacillus cereus _ Culture & Smear
_ B. pertussis _ Mycobacteria ID
City: _______________________ State: ____ Zip: ________ _ Campylobacter spp
Telephone No.: ________________ Fax No.: __________________ _ Carbapenem Resistant Org LEGIONELLA
Organism: _________________ _ Culture
Physician (Full Name): ______________________________________ _ C. botulinum/tetani _ DFA
_ C. diphtheriae
OTHER Report to: _______________________________________ _ Cryptosporidium CDC Study PARASITOLOGY
PATIENT INFORMATION - Please Print Legibly _ EHEC/Shiga-like toxin _ *Blood Parasite*
_ H. influenzae (Need travel history)
NOTE: All specimens MUST have Date of Birth and Date of Collection; _ Hep A Virus Genotyping
Patient Address is needed for State requested or outbreak investigation testing; _ Legionella spp PERTUSSIS
Medicaid patients need Medicaid # and ICD (Diagnosis) Code for billing purposes _ Listeria spp _ Culture
_ M. tuberculosis _ PCR
_ N. gonorrhoeae
Last Name: ____________________________________________________ _ N. meningitidis SYPHILIS
_ Plasmodium/Babesia _ RPR – Qual - Screen
First Name: ___________________________________________________ _ Salmonella spp _ RPR – Quant - Titer
_ Shigella spp _ TP-PA
Patient ID #: ___________________________________________________ _ Strep. pneumoniae _ VDRL (CSF only)
_ Vibrio spp
_ Yersinia spp VIRUS TESTING
D.O.B: Age: ________ Sex: M F _ Arbovirus IgM
MM/DD/YY _ Chikungunya RT-PCR
BACTERIAL CULTURE/ISOLATE ID _ *COVID-19
Address: __________________________________________________ _ Aerobic Coronavirus*
City: ____________________ State: _________ Zip: _____________ _ Anaerobic _ Herpes 1&2 IgG Ab
_ Antimicrobial Susceptibility _ Measles (Rubeola) IgG
Patient Tel #: _______________________________________________ _ Enteric Culture _ Measles (Rubeola) IgM
Race (Circle One): WHITE BLACK ASIAN _ Screen (Salmonella, Shigella only) _ Measles RT-PCR
_ Full – (Salmonella, Shigella, _ Mumps IgG
Check if patient is:
NATIVE–American/Alaskan MULTIRACIAL Campylobacter, Aeromonas,
_ Healthcare Worker _ Mumps RT-PCR
Plesiomonas, EHEC, Yersinia)
_ Inpatient HAWAIIAN/PACIFIC ISLANDER UNKNOWN _ Norovirus RT-PCR
_ Isolate ID: _____________
_ Emergency Responder _ Respiratory Panel
OTHER ___________
_ Long Term Care resident CHEMISTRY (Amplified)
Ethnicity (Circle One): NON-HISPANIC _ Arsenic – Total, Urine _ Rubella IgG
_ Metals, Blood _ Varicella-Zoster IgG
HISPANIC UNKNOWN
_ Other _________ _ Other ________
SPECIMEN INFORMATION: DATE of collection: ________________
CHLAMYDIA COMMENTS:
TIME of collection: ________________ _ Amplified
SITE/SOURCE of Specimen (please check):
GONORRHEA
___ Serum ___ Rectal _ Amplified
___ Whole Blood ___ Stool _ Culture
___ Sputum ___ Throat
HEPATITIS
___ Bronchial Washing ___ Urethra
_ A IgM Ab
___ CSF ___ Urine PHL USE ONLY
_ A Total Ab
___ Cervix ___ Vagina _ B Core IgM Ab
___ Nasopharyngeal ___ Tissue (Specify) ______________ _ B Core Total Ab
___ Oropharyngeal ___ Fluid (Specify) _______________ _ B Surface Ab
___ Other (Specify) ______________ _ B Surface Ag
Date of Onset of Symptoms: _ C Ab – Screen
_ C Genotyping
*PATIENT TRAVEL HISTORY*: (Please supply date(s) and location) _ C RNA Quantitative

Other Test Requested or Additional Comments and Remarks: ___________________________________________________________________________________3/20/2020