Laboratory Testing, Supplies & Reporting
Laboratory Test Request Forms
Laboratory Test Request forms are submitted for immunological evidence of infection from blood and CSF specimens and for isolation and/or identification of bacteria, fungi, parasites, or viruses.
Completing the Laboratory Test Request Form:
This form may be used for patient specimens, inoculated media, and Title 17 Submissions. Fill in the laboratory test request form as completely as possible. Print all information legibly. Printed adhesive labels may be used to label forms and specimens.
- Patient Information: Fill in patient information in the upper section: Last name, First name, gender, and date of birth. Fill in Patient Address, City, State, and Zip Code. If available, include Patient Medical Record Number and Reference or Submitter Sample Number. Always verify that the name on the requisition and the name on the specimen are in agreement.
- NOTE: California Title 17 requires patient pregnancy status, ICD-10 Diagnosis Codes, race and ethnicity on all reportable test submissions. Gender at birth, gender identity, and sexual orientation may also be reportable patient information.
- Specimen Collection Date and Time: Fill in the date and time of specimen collection.
- Submitting Facility and Ordering Provider: Fill in the submitter facility name and address in the upper left section. Fill in the ordering provider name and NPI#. If the facility is new to the laboratory, contact information and reporting preference should be included.
- Test and Specimen: Mark the box for the test requested in the lower portion of the form. If the test requested is not listed, write the test name or description in the “Additional Comments/Information” section. For each test requested mark the appropriate box for the specimen source in the middle of the form. If specimen source is not listed, fill in under “Other”. Indicate below the specimen sources if the specimen type is submitted as an isolate, swab or other type. One form may be used for multiple specimens from the same patient. Mark all the specimen sources and all the tests requested.
Submission of Specimen: Submit the original request with the specimen(s). Do not transport Laboratory Request Forms in direct contact with specimen primary containers to avoid contamination of the form. The form should be in an outer pocket of a plastic specimen bag or around the specimen secondary container.
Completing Specialized Laboratory Test Requisition Forms:
- Bacterial Culture for Identification: Use for bacterial isolates from clinical laboratories, including actinomycetes. Fill in the form as completely as possible.
- Rabies FRA Submission Form: Use to submit animal heads or brain material for rabies testing from animal control agencies and animal hospitals. Instructions for specimen submission are on the reverse of the form.
Most routine supplies needed to submit specimens to the Public Health Laboratory are provided free of charge. A laboratory supplies requisition form is available upon request for your orders. All orders may be mailed, faxed to (909) 986-3590, or delivered to the public health laboratory for delivery that week.
Laboratory test results are faxed as a single 8 ½ x 11-inch report. The report form includes comprehensive patient information as well as test results. Requests for copies of final reports must be submitted to the lab office staff by fax. Anyone who requires additional information on patient test results should contact the laboratory.