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MDL Form 176 – Adult C. Botulinum Toxin Detection 

Electronic Submittal Form Instructions

Use Lab Form 176 - Adult C. Botulinum Toxin Detection (PDF) to submit specimens. 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 1, under “Select Test Requisition,” use the pull down menu to select Lab Form “Adult C. Botulinum Toxin Detection-176.” 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. All botulism testing must be approved by CDPH Division of Communicable Disease Control Subject Matter Experts or Duty Officer PRIOR to submission. Specimens submitted without approval will not be tested.

3. Follow the instructions below to provide additional information on page 2:

3.1. Indicate the suspected case type, if known.

3.2. Indicate if neostigmine class drugs have been administered and if tensilon test has been performed.
3.3. Indicate if heptavalent botulinum antitoxin (HBAT) was administered.

4. Print the completed Lab Form 176 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 in compliance to federal and state packaging and shipping regulations.

6. Additional considerations when submitting samples:
6.1. Clinical specimens should be appropriately sealed to prevent leakage during transport.
6.2. If submitting a culture isolate, it should be a pure culture in a taped tube of anaerobic growth medium that supports Clostridium botulinum.
6.3. Do not submit isolates on agar plating medium.
6.4. Label sample tube with at least two identifiers (i.e. the patient’s name, submitter lab number, date of birth) and the date collected.
6.5. Before shipment, insert the completed Lab Form 176 and all attachments between the inner and outer shipping containers.
6.6. Follow all other submission guidelines as described in the “General Specimen Submission Instructions” (PDF) and guides located on the MDL Services and Test Catalog website.
6.7. If you have any questions regarding sample submission, call the MDL for guidance - (510) 412-3700.

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