Microbial Diseases Laboratory

MDL Form 414 – Feces for Bacterial Culture

Electronic Submittal Form Instructions

Use Lab Form 414 – Feces for Bacterial Culture to submit fecal specimens or fecal enrichment broths. 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 “Feces for Bacterial Culture-414”. 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 414, it is REQUIRED that the following additional fields be filled in:

2.1. Field 12 (Patient Street Address).
2.2. Field 13 (City).
2.3. Field 15 (State).
2.4. Field 16 (Zip).
2.5. Field 39 (Test(s) Requested).
2.6. Field 41 (Clinical History).

3. Follow the instructions below to provide additional information on page 2 “Feces for Bacterial Culture-414 - Additional Specimen Information":

3.1. Feces Appearance (if available):

3.1.1. Indicate if this is an initial specimen from a patient (“1st specimen”) or if it is a follow up specimen for clearance (“2nd” or “3rd”).
3.1.2. Check any appropriate descriptors for the fecal specimen appearance.

3.2. Culture Independent Diagnostic Test (CIDT):

3.2.1. If results for a CIDT are available, select the platform used from the drop-down list. If “Lab developed test (LDT)” is selected enter a description of the LDT in the blank to the right.
3.2.2. If the specific platform used is not listed select “Other platform” and enter the name of the platform in the blank to the right.
3.2.3. REQUIRED Check all analytes that were positive by CIDT. If the analyte(s) is not listed check “other” under bacterial and enter the analyte(s) identified; enter the information in this field regardless if the analyte is bacterial or not. Include the CT values results from the CIDT if available.
3.2 Comment

Used for other information.

4. Print the completed Lab Form 414 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 the 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 414 and all attachments between the inner and outer shipping containers.
6.5. Follow all other submission guidelines as described in 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.