New Jersey Department of Health

Public Health and Environmental Laboratories

PO Box 361

Trenton, NJ 08625-0361

REQUISITION FOR VIRAL SEROLOGY

Testing for viral serology is done on serum and cerebrospinal fluid (CSF) specimens. Please send at least 2 ml of serum and at least 1 ml of CSF for proper testing to proceed. Specimens should be maintained at 2-4( C and shipped on ICE to the Lab, with the completed form. Testing for West Nile Virus (WNV) requires acute and convalescent sera. Acute serum and CSF should be drawn 8 -10 days after onset of symptoms. Convalescent serum should be drawn 14 - 21 days after the acute sample. Red Top Tubes ONLY, no hemolysin. Red Top Separator Tubes are acceptable to use.

IMPORTANT: Results will be faxed to the submitter.	STATE LAB USE ONLY
Date Received
Accession No.
(Please print clearly with black ballpoint pen.)
Patient Name (Last) (First) (MI)

DOB

/ /	Age

Sex

Male

Female
Street Address

City State Zip Code

Onset Date

Dx or Test(s) Requested

FAX REPORT TO	Physician Name and Address (Print)

Telephone Number

( )
Fax Number (REQUIRED)

( )
Type of Specimen and Date(s) Collected	Travel History

Domestic (Outside NJ):	Yes	No

Where (List):

When (List Date(s) of Travel):

Foreign (Outside of Continental US):	Yes	No

Where (List Country, etc.):

When (List Date(s) of Travel):
SERUM
DATE
Acute
Convalescent
CSF
Vaccination History

Yellow Fever Vaccine: Yes No

Date(s) given (List):
1. Pertinent Clinical Information - Brief history; clinical findings; relevant lab data.

2. CSF Results:

Total WBC Differential %POLYS %LYMPHS PROTEIN mg% GLUCOSE mg%
Following the above criteria will help to ensure the most complete and accurate results possible. Failure to follow the above instructions and/or provide the information requested may cause delays in processing and/or indeterminate/inconclusive results.

VIR-1

JUL 12	Distribution: Original - NJDOH Copy - Submitter

VIR-1, Requisition for Viral Serology

VIR-1, requisition for vital serology,

EWhite

2001-05-02

NJDOH