Forms

Forms

All forms available for download are on this page.

CDC Submission Form 50.34: https://www.cdc.gov/laboratory/specimen-submission/form.html    (open in Internet Explorer, not Google Chrome)

Chain of Custody for Microbiology

        CLIA Certificate

Confidential Disease Report

Courier Locations and Service Days

Credit Card Authorization Form

Environmental Health Departments (assist with private water well disinfection)

FAX Request for Test Results (fillable pdf) Healthcare providers only, not for patient use

Influenza Virus Collection Protocol 

        Lab Requisition – Lab Web Portal

Authorization to Release Health Records (patient only, not for HCP)

Reportable Diseases and Conditions

        Submitter Verification Form

Supplemental Questionnaire for TB NAAT (fillable pdf)

Supply Order Form-Fillable

        Supply Order Form-Printable

Water Collection Protocol

Water Analysis Request Form

West Nile Virus Submission Protocol

West Nile Virus Testing Guidelines

        WPHL Risk Assessment Form