Forms

Forms

All forms available for download are on this page.

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

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 Virus Collection Protocol 

Influenza Test Requisition

          Lab Requisition – Lab Web Portal

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

QFT Plus Requisition Form

Reportable Diseases and Conditions

         Secure Fax Verification Form

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 Form