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MICROBIAL DISEASES LABORATORY

General Specimen Submission Page 1 Instructions

 Detailed instructions are provided on how to fill in each field. Instructions are also built into the pdf and can be viewed by hovering the cursor over the input field. An example form with the fields numbered for reference is shown below.

General Specimen Submission page with markups from 1 to 41

Input Field Instructions

​Input Field

Instructions

1. Select Test Requisition
REQUIRED - Select the appropriate form from the drop-down list prior to entering information.
2. Patient – Last Name
REQUIRED - Enter the patient’s last name.
3. First Name
REQUIRED - Enter the patient’s first name.
4. MI
​Enter middle initial if available.
5. DOB
REQUIRED - Select patient’s date of birth using the drop-down calendar, or enter the date formatted as MM/DD/YYYY.
6. Age
​Enter the patient’s age.
7. Units
REQUIRED - if Age is provided Select the units for age from the drop-down list.
8. Gender
REQUIRED - Select the patient’s gender from the drop-down list.
9. Ethnicity
​Select the patient’s ethnicity from the drop- down list.
10. Race
​Select the patient’s race from the drop-down list.
11. Pregnancy Status
​Select the patient’s pregnancy status from the drop-down list.
12. Patient Street Address
​Enter the street address of the patient’s residence.
13. City
​Enter city of patient’s residence.
14. County
​Select the patient’s county of residence from the drop-down list. If the patient is not a resident of California, select the State of residence and then type the name of the county in the field.
15. State
​Select the patient’s state of residence from the drop-down list.
16. Zip
​Enter the 5-digit patient zip code.
17. Suspected Disease
​Enter the most appropriate disease suspected. Provide details/symptoms in field 41 “Brief clinical history, symptoms, therapy (e.g. treatment received), treatment outcome.”
18. Onset Date
​Select the onset date using the drop-down calendar or enter the date formatted as MM/DD/YYYY.
19. Onset Date Modifier
​Select the accuracy of the onset date from the drop-down list.
20. Patient Medical Record #
​Enter the patient’s medical record number if available.
21. CalREDIE #
​Enter CalREDIE number.
22. ICD Code
​Enter ICD Code.
23. Travel History
​Enter any relevant travel information related to the patient.
24. Original Submitting Physician
​Provide the name of the clinician who diagnosed the patient and can provide answers to any questions regarding patient information or condition.
25. Phone
​Provide the phone number of the clinician who diagnosed the patient formatted as 10 digits no dashes or spaces (i.e. 5554442222).
26. Name
​REQUIRED - Enter the name of the
submitting laboratory. The testing report will be returned to the submitter. A stamp or sticker may be used to enter this information.
27. Address
​Enter the address of the submitting laboratory.
28. Email
​Enter email address of submitter if available.
29. Submitter Specimen #
REQUIRED - Enter the specimen number assigned by your lab.
30. Phone
​Enter the phone number of the submitting laboratory formatted as 10 digits no dashes or spaces (i.e. 5554442222).
31. Fax
​Enter the Fax number of the submitting laboratory formatted as 10 digits no dashes or spaces (i.e. 5554443333).
32. Date Collected
REQUIRED - Enter the date the specimen was collected using the drop-down calendar, or enter the date formatted as MM/DD/YYYY.
33. Time
​Enter the time the specimen was collect formatted as HHMM (military time). Do not include a colon.
34. Material Submitted
REQUIRED - Select the type of material submitted from the drop-down list (e.g. for human specimens such as stool or sputum, select “Original Material”). If “Other-Specify below” is selected, please specify in the “Material comments” field below (field 35).
35. Material Comments
​This field is free text and is used when “Other- Specify below” is selected for the “Material Submitted” (field 34) or “Other” is selected for “Source” (field 37).
36. Material Type Modifier
​Select the modifier submitted from the drop- down list.
37. Source
REQUIRED - Select the appropriate specimen source from the drop-down list. If “Other” is selected, please specify in “Material Comments” (field 35).
38. Source Site
​Enter the source site.
39. Test(s) Requested
REQUIRED - Enter all laboratory tests requested.
40. Submitter’s Identification of Organism
​Enter the submitter’s identification of the organism. Additional details may be entered on the second page of this form.
41. Brief clinical history, symptoms, therapy (e.g. treatment received), treatment outcome
​Enter any known clinical history, such as, symptoms, treatment therapy, or treatment outcome.


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