New Jersey Department of Health

P. O Box 361

Trenton, NJ 08625-0361

REQUEST FOR IMMUNOLOGICAL/ISOLATION SERVICES

-CLINICAL SERVICES TESTING UNIT-
Lab ID No.
COMPLETE ALL INFORMATION - MUST BE LEGIBLE TO AVOID PROCESSING DELAYS!

Name (Last, First, MI)

Zip Code

Patient ID/SSN

Address

City

Sex

Male	Female	DOB

/ /	Ethnicity

Hispanic/Latino	Non-Hispanic/Non-Latino
Race

White (European, No. African, Middle Eastern)	Native Hawaiian or Other Pacific Islander	Asian

American Indian or Alaskan Native	Black or African American	Other
Specimen Type

Date/Time	Date/Time	Date/Time
Serum:
Bronchial	Tick
Acute	Sputum	Other (Specify):
Convalescent	CSF
Exposure Date

Pertinent Clinical Information (brief history, clinical findings, relevant lab data)
Onset Date

Tests Requested

Tick-borne Disease Testing

92010 Tick Identification Only

92020 Lyme Disease Isolation (Tick)

92025 Lyme Disease Isolation (Tissue, Joint Fluid, etc.)

92030 Lyme Disease Serology

92040 Human Granulocytic Ehrlichiosis

92050 Human Monocytic Ehrlichiosis

92060 Rocky Mt. Spotted Fever (Tick)

92080 Rocky Mt. Spotted Fever Serology

Fungal Serologies

92090 Aspergillosis

92100 Blastomycosis

92110 Coccidioidomycosis

92120 Histoplasmosis

92130 Cryptococcosis

Legionella Testing

92140 Culture (Human)

92145 Culture (Environmental)

92150 Legionella Serology

Other Tests (specify):	Date/Time Received
Physician Name (Print)

Submitter Name and Mailing Address Information

Physician Telephone Number

( ) -
(Name)
Physician Fax Number (including area code)

(if you would like results faxed)

( ) -
(Address)
(City) (State) (Zip)
SRD-4

AUG 12

REQUEST FOR IMMUNOLOGICAL/ISOLATION SERVICES

-CLINICAL SERVICES TESTING UNIT-

(SRD-4) FORM

Instructions

IMPORTANT - PLEASE READ BEFORE COMPLETING FORM

COMPLETE ALL INFORMATION - MUST BE LEGIBLE TO AVOID PROCESSING DELAYS

FOR FURTHER INFORMATION AND PRICING, CALL 609-292-5819.

COMPLETE ONE FORM FOR EACH PATIENT: give all information requested on form

ISOLATION

Collect specimens aseptically as soon as possible after onset or at autopsy. Label each specimen with patient identification, type of specimen, and date of collection. REFRIGERATE IMMEDIATELY, keep cold, and deliver to State Laboratory.* If delivery is delayed longer than 24 hours, specimens should be frozen at coldest temperature, -70 C. Do not add preservatives or fixatives.

IMMUNOLOGY

Acute and convalescent serum specimens are necessary to determine an immunologic response has occurred or increase in titer during the course of illness. Specimens should be submitted together unless prior arrangements have been made to test acute or only an acute specimen is appropriate.

Acute:	Collect as soon as possible, preferably within 7 days of onset. Label with patient’s name and date collected on tube and form.

Convalescent:	Collect 2 - 3 weeks after onset (Legionella 3 - 6 weeks; Lyme 6 - 12 weeks, preferably 6; Rickettsiae 4 - 6 weeks)

Amount:	Submit 3 - 4 ml. of serum; no preservatives. Hemolyzed specimens are not acceptable.

TICK SUBMISSION

Place tick in a test tube or other airtight container (film canister, pill bottle).

Add moistened piece of paper towel, paper napkin, or cotton.

If submission is not immediate, refrigerate tick until ready for submission (no longer than 24-48 hrs.)

Label tick container with your name and date collected.

*DELIVERY

Ground deliveries should be made to:

NJ Department of Health

Public Health and Environmental Laboratories

Specimen Receiving Unit

3 Schwarzkopf Drive

Ewing, NJ 08628

SRD-4, Request for Immunological/Isolation Services

PUBLIC HEALTH AND ENVIRONMENTAL LABS, CLINICAL SERVICES, SPECIMEN RECEIVING AND DISTRIBUTION, TESTING SERVICES

EWhite

2004-05-12

NJDOH