Forms

Manual of Laboratory Services

Here is the link to the current version of the WPHL Manual of Laboratory Services.  Listed contacts may be inaccurate due to staffing turnovers.   Please refer to the website for the most accurate contacts and services offered.

Forms

All forms available for download are on this page.

         APHL Risk Assessment Template

CDC Submission Form 50.34: http://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

Courier Service Instructions

Credit Card Authorization Form

Environmental Health Departments (assist with private water well disinfection)

EV-D68 Requisition Form

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

Influenza Collection Protocol

Influenza Test Requisition

Laboratory Requisition Form

        Laboratory Requisition Form – Fillable Submitter

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

QFT Plus Requisition Form

Reportable Diseases and Conditions

Supplemental Questionnaire for TB NAAT (fillable pdf)

Supply Order Form – Fillable Version

        Supply Order Form – Printable Version

Water Collection Protocol

Water Testing Requisition Form

West Nile Virus Submission Protocol

West Nile Virus Testing Guidelines

        WPHL Risk Assessment Template