Form OL-9B "Clinical Test Requisition" - Connecticut

What Is Form OL-9B?

This is a legal form that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 9, 2015;
  • The latest edition provided by the Connecticut State Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form OL-9B by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Public Health.

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Download Form OL-9B "Clinical Test Requisition" - Connecticut

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CLINICAL TEST REQUISITION
Name and Address of Authorized Submitter
STATE OF CONNECTICUT
ACCESSION LABEL
Dr. Katherine A. Kelley State Public Health Laboratory
395 West Street, Rocky Hill, CT 06067
FOR LABORATORY USE
CLIA ID 07D0644555 / CT License CL-0197
ONLY
Phone 860-920-6500
CLIENT SERVICES 860-920-6635
LAB PROFILE Number:
 DENOTES REQUIRED INFORMATION
Section 1: Patient Information
(Please Print Clearly)
Name (Last, First, M.I.) or Identifier:
Street Address:
City, State, Zip:
Date of Birth:
Gender:  Female
 Male
 Unknown
Home Phone:
Race (check all that apply):
( Race/Ethnicity Information is Required for Blood Lead)
 White  Black/African Amer.  Asian  Amer. Indian/Alaska Nat.  Nat. Hawaiian/Other Pacific Islander  Other  Unknown
Ethnicity:  Hispanic
 Non-Hispanic
 Unknown
International travel within the past 21 days?  Yes  No  Unknown Location(s) ______________ ______________ ______________
Ordering Healthcare Provider:
Phone:
Section 2: Specimen Information
Submitter Sample ID:
Date Collected:
Time Collected:
 AM  PM
Specimen Source/Type:
 Blood
 Bronchial Wash
 Cervix
 CSF
 Lymph Node
 Nasopharynx
 Oral Fluid
 Rectal
 Serum
 Sputum
 Stool
 Throat
 Urethra
 Urine
 Body Fluid, specify ____________________________________
 Tissue, specify ________________________________________
 Other, specify _______________________________________________________________________
Section 3: Select Testing Requested
Bacteriology
Virology
 AFB Clinical Specimen
 Arbovirus Panel
(Mycobacteria Smear & Culture)
(Encephalitis Viruses)
 AFB Referred Culture
California Group, Eastern Equine, St. Louis, Western Equine
(Mycobacteria for Identification)
 Cytomegalovirus IgG Antibody
 Bioterrorism Agent Identification
 Cytomegalovirus IgM Antibody
specify agent:____________________________________
 Bordetella pertussis
 Hepatitis B Surface Antibody
(DFA, Culture, or Isolate)
 Chlamydia & Gonorrhea DNA Probe
 Hepatitis B Surface Antigen
 EIP Isolates for Identification
 Hepatitis C Testing
(Check one)
 Herpes Simplex IgG Antibody
Group A Streptococcus
H. influenzae
L. monocytogenes
N. meningitidis
S. pneumoniae
Other: ___________________
 Herpes Simplex PCR
 Enteric Isolate for Identification
 HIV-1/HIV-2 Testing
Campylobacter
E. coli O157
Salmonella
Shigella
 HIV STARHS Referral
Shiga-toxin producing E. coli
Vibrio
Other: ________________
 Influenza PCR
 Enteric (Stool) Culture
 Measles PCR
 Neisseria gonorrhoeae Culture
 MERS CoV
(Epidemiology Approval Required)
 Shiga-toxin (+) Broth Culture
 Mumps PCR
 Norovirus PCR
Bacterial Serology
(Epidemiology Approval Required)
 Respiratory Virus Antigen Panel:
Adenovirus, Influenza A&B,
 QuantiFeron-TB Test
(Specify  Date & Time Collected Above)
Metapneumovirus, Parainfluenza 1-3, Rhinovirus/Enterovirus, RSV A&B
 Syphilis Screen (VDRL)
 Varicella Zoster IgG Antibody
 Syphilis Confirmation (VDRL & TP-PA)
 West Nile Virus IgM Antibody
 Syphilis CSF (VDRL Only)
 Virus Identification
(Culture)
Blood Lead
(Uninsured Patients ONLY)  Race/Ethnicity Required
Test, Agent or Disease, Not Listed (Specify)
 Child Lead Screen (Capillary Blood)
 Lead Confirmation (Venous Blood)
Comments
Parasitology
(270 spaces)
 Blood Parasite - Smear
 Parasite (Fecal) – Gross Identification
For Laboratory Use Only
Form OL-9B Rev. 04/9/2015
CLINICAL TEST REQUISITION
Name and Address of Authorized Submitter
STATE OF CONNECTICUT
ACCESSION LABEL
Dr. Katherine A. Kelley State Public Health Laboratory
395 West Street, Rocky Hill, CT 06067
FOR LABORATORY USE
CLIA ID 07D0644555 / CT License CL-0197
ONLY
Phone 860-920-6500
CLIENT SERVICES 860-920-6635
LAB PROFILE Number:
 DENOTES REQUIRED INFORMATION
Section 1: Patient Information
(Please Print Clearly)
Name (Last, First, M.I.) or Identifier:
Street Address:
City, State, Zip:
Date of Birth:
Gender:  Female
 Male
 Unknown
Home Phone:
Race (check all that apply):
( Race/Ethnicity Information is Required for Blood Lead)
 White  Black/African Amer.  Asian  Amer. Indian/Alaska Nat.  Nat. Hawaiian/Other Pacific Islander  Other  Unknown
Ethnicity:  Hispanic
 Non-Hispanic
 Unknown
International travel within the past 21 days?  Yes  No  Unknown Location(s) ______________ ______________ ______________
Ordering Healthcare Provider:
Phone:
Section 2: Specimen Information
Submitter Sample ID:
Date Collected:
Time Collected:
 AM  PM
Specimen Source/Type:
 Blood
 Bronchial Wash
 Cervix
 CSF
 Lymph Node
 Nasopharynx
 Oral Fluid
 Rectal
 Serum
 Sputum
 Stool
 Throat
 Urethra
 Urine
 Body Fluid, specify ____________________________________
 Tissue, specify ________________________________________
 Other, specify _______________________________________________________________________
Section 3: Select Testing Requested
Bacteriology
Virology
 AFB Clinical Specimen
 Arbovirus Panel
(Mycobacteria Smear & Culture)
(Encephalitis Viruses)
 AFB Referred Culture
California Group, Eastern Equine, St. Louis, Western Equine
(Mycobacteria for Identification)
 Cytomegalovirus IgG Antibody
 Bioterrorism Agent Identification
 Cytomegalovirus IgM Antibody
specify agent:____________________________________
 Bordetella pertussis
 Hepatitis B Surface Antibody
(DFA, Culture, or Isolate)
 Chlamydia & Gonorrhea DNA Probe
 Hepatitis B Surface Antigen
 EIP Isolates for Identification
 Hepatitis C Testing
(Check one)
 Herpes Simplex IgG Antibody
Group A Streptococcus
H. influenzae
L. monocytogenes
N. meningitidis
S. pneumoniae
Other: ___________________
 Herpes Simplex PCR
 Enteric Isolate for Identification
 HIV-1/HIV-2 Testing
Campylobacter
E. coli O157
Salmonella
Shigella
 HIV STARHS Referral
Shiga-toxin producing E. coli
Vibrio
Other: ________________
 Influenza PCR
 Enteric (Stool) Culture
 Measles PCR
 Neisseria gonorrhoeae Culture
 MERS CoV
(Epidemiology Approval Required)
 Shiga-toxin (+) Broth Culture
 Mumps PCR
 Norovirus PCR
Bacterial Serology
(Epidemiology Approval Required)
 Respiratory Virus Antigen Panel:
Adenovirus, Influenza A&B,
 QuantiFeron-TB Test
(Specify  Date & Time Collected Above)
Metapneumovirus, Parainfluenza 1-3, Rhinovirus/Enterovirus, RSV A&B
 Syphilis Screen (VDRL)
 Varicella Zoster IgG Antibody
 Syphilis Confirmation (VDRL & TP-PA)
 West Nile Virus IgM Antibody
 Syphilis CSF (VDRL Only)
 Virus Identification
(Culture)
Blood Lead
(Uninsured Patients ONLY)  Race/Ethnicity Required
Test, Agent or Disease, Not Listed (Specify)
 Child Lead Screen (Capillary Blood)
 Lead Confirmation (Venous Blood)
Comments
Parasitology
(270 spaces)
 Blood Parasite - Smear
 Parasite (Fecal) – Gross Identification
For Laboratory Use Only
Form OL-9B Rev. 04/9/2015