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Microbial diseases laboratory

MDL Form 416 – Parasitology

Electronic Submittal Form Instructions

Use Lab Form 416 - Parasitology to submit specimens for PCR testing of Plasmodium species, Entamoeba histolytica, Giardia lamblia, Cryptosporidium sp., Cyclospora cayetanensis or referrals to CDC. Use the following steps to enter information for the submission of each specimen.

NOTE: We are unable to process samples with inadequate information.

1. On page one, under “Select Test Requisition”, use the pull-down menu to select Lab Form “Parasitology-416”. Provide all necessary information on page 1. For directions on how to fill out the fields on page 1, please refer to the “General Specimen Submission Page 1 Instructions” page.

2. For MDL form 416, it is REQUIRED that the following fields be filled in:
2.1. Field 23 (Travel History).
2.2. Field 39 (Test(s) Requested).
2.3. Field 40 (Submitter’s identification of Organisms).
2.4. Field 41 (Clinical History, treatments received).

3. Follow the instructions below to provide additional information on page 2 “Parasitology-416 - Additional Test Information":

3.1. Check box to indicate the test requested.

3.2. If referral to CDC, type in the test requested.

4. Print the completed Lab Form 416 front to back. The document is formatted for 2-sided printing.

5. Packaging and shipping: The submitter is responsible for making sure that all samples are packaged and shipped according to the current federal and state packaging and shipping regulations for “Infectious substance, Category A” and/or “Biological substance, Category B”.

6. Additional considerations when submitting samples:
6.1. Clinical specimens should be appropriately sealed to prevent leakage during transport.
6.2 Label sample tube with at least two identifiers (i.e. the patient’s name, submitter lab number, date of birth) and the date inoculated.
6.3. For safety, all submitted sample tubes must have a tightened screw cap secured in place using tape.
6.4. Before shipment, insert the completed Lab Form 416 and all attachments between the inner and outer shipping containers.
6.5. Follow all other submission guidelines as described in the “General Specimen Submission Instructions” and guides located on the MDL Services and Test Catalog website.
6.6. If you have any questions regarding sample submission, call the MDL for guidance – 510-412-3700.

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