MAIL RESULTS TO: COUNTY ( ) - FAX # PATIENT ADDRESS CITY NAME ZIP CODE STATE YR DAY MO FEMALE MALE DATE OF BIRTH COUNTY (LAST) TISSUE (SPECIFY) WOUND (SITE) FLUID (SPECIFY) OTHER (SPECIFY) THROAT NASOPHARYNGEAL DATE BEGUN : MO TIME OF DAY SMEAR CULTURE OTHER (SPECIFY) DATE SENT TO STATE MO DAY YR MO DAY YR TIME OF DAY : AM PM PM AM HAVE SPECIMENS FROM THIS PATIENT BEEN SUBMITTED PREVIOUSLY? YES NO SERUM STOOL TREATMENT SUBMITTER ( ) - AREA CODE & PHONE # DAY YR DATE COLLECTED DATE OF ONSET PLEASE ATTACH YOUR TEST RESULTS : DATE COMPLETED DRUGS USED (FIRST) (MI) NAME OF PERSON COMPLETING THIS FORM PHONE # ( ) - SUBMITTER'S LAB NUMBER: SPECIMEN SUBMITTED IS: MIXED ISOLATE ORIGINAL MATERIAL PURE ISOLATE MICROBIOLOGY CLINICIAN CLINICIAN'S PHONE # ( ) - CITY, STATE, ZIP CODE: SPECIMEN INFORMATION LABORATORY EXAMINATION REQUESTED: DAY MO YR DAY MO YR Please Print Clearly CHART OR PATIENT ID NUMBER MOLECULAR DIAGNOSIS/ PCR SINGLE CASE OUTBREAK SUSPECTED SOURCE OF INFECTION: SPECIMEN IS FROM TRAVEL HISTORY (CONTINUE TRAVEL HISTORY IN COMMENTS, IF NECESSARY) FOREIGN TO CONTACT CARRIER DAY MO YR DAY MO YR TO DAY MO YR DAY MO YR FOR PHL USE ONLY Date/Time Received Lab Number ATTENTION: (See Instructions on Reverse Side of Form) BACTERIOLOGY USA COMMENTS Public Health Laboratories State of Washington Department of Health PUBLIC HEALTH LABORATORIES 1610 N.E. 150th Street Shoreline, Washington 98155-9701 Phone: (206) 418-5400 Fax: (206) 364-0072 MTS #1327 CLIA #50D0661453 FOR PHL USE ONLY Date/Time Reported: URO-GENITAL URINE RECTAL SWAB DOH 302-013 (06/2018) FATAL? NO YES BLOOD SPUTUM CSF BRONCHIAL WASH EPIDEMIOLOGY SPECIFIC AGENT SUSPECTED: MEDIA USED FOR SUBMISSION OF SPECIMEN (SPECIFY): GASTRIC IDENTIFICATION/CONFIRMATION IS THIS REQUEST INVOLVED IN A MEDICAL-LEGAL SITUATION? YES NO MOLECULAR DIAGNOSIS/PCR PARASITOLOGY VACCINATION HISTORY MYCOBACTERIOLOGY (TB) PFGE SEROLOGY ANTIMICROBIAL SUSCEPTIBILITY