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.
|