Form MDL-VPP-01 "Bacterial Sepsis/Meningitis Pcr Specimen Test Request" - California

What Is Form MDL-VPP-01?

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

Form Details:

  • Released on July 1, 2016;
  • The latest edition provided by the California 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 MDL-VPP-01 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form MDL-VPP-01 "Bacterial Sepsis/Meningitis Pcr Specimen Test Request" - California

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State of California--Health and Human Services Agency
California Department of Public Health
Microbial Diseases Laboratory
(CLIA ID No. 05D0643851) | 850 Marina Bay Parkway, E164 | Richmond, CA 94804 | (510) 412-3700
Bacterial Sepsis/Meningitis PCR Specimen Test Request
MDL Accession Number:
(Please complete required information as much as possible)
Date Received:
Description of Specimen
Patient's
name (last, first)
Age or DoB
Gender
Date
collected
Patient's address
Specimen Source
preservative:
Blood
CSF
volume:
Physician's
Name
(specify):
Other
Original specimen
Gram stain results
Phone Number
Clinical condition
or suspected disease
Date of culture
Final culture results & date reported
Yes
No
Antibiotics administered? (Check one):
Yes
No
If Yes, was it given before s pecimen collection?
(Note: PCR will not be done on culture-positive s pecimen.)
CSF Specimen Only Exam Results:
Submitters
Name:
WBC count:
Address:
Protein:
Glucose:
Phone number:
Fax number:
Major clinical findings, travel history, treatment & date given (please include vaccine history)
Do not fill out below this line
Report of State Laboratory Investigation
Neisseria meningitidis
DNA detected by PCR
Streptococcus pneumoniae
DNA detected by PCR
Streptococcus pneumoniae
Serogroup B
DNA not detected by PCR
Streptococcus pneumoniae
Serogroup C
PCR not performed
Serogroup Y
Haemophilus influenzae
Serogroup undetermined
DNA detected by PCR
Neisseria meningitidis
Haemophilus influenzae
DNA not detected by PCR
DNA not detected by PCR
Neisseria meningitidis
Haemophilus influenzae
PCR not performed
PCR not performed
I
. --Please submit new sample.
NO EXAM MADE
NADEQUATE SPECIMEN FOR TESTING
Comments
Disclaimer: This test was developed and its performance characteristics determined by the Microbial Diseases Laboratory of the California Department of Public Health.
It has not been cleared or approved by the U.S. Food and Drug Administration.
Date reported
Report approved by
MDL-VPP-Form01 (7/16)
State of California--Health and Human Services Agency
California Department of Public Health
Microbial Diseases Laboratory
(CLIA ID No. 05D0643851) | 850 Marina Bay Parkway, E164 | Richmond, CA 94804 | (510) 412-3700
Bacterial Sepsis/Meningitis PCR Specimen Test Request
MDL Accession Number:
(Please complete required information as much as possible)
Date Received:
Description of Specimen
Patient's
name (last, first)
Age or DoB
Gender
Date
collected
Patient's address
Specimen Source
preservative:
Blood
CSF
volume:
Physician's
Name
(specify):
Other
Original specimen
Gram stain results
Phone Number
Clinical condition
or suspected disease
Date of culture
Final culture results & date reported
Yes
No
Antibiotics administered? (Check one):
Yes
No
If Yes, was it given before s pecimen collection?
(Note: PCR will not be done on culture-positive s pecimen.)
CSF Specimen Only Exam Results:
Submitters
Name:
WBC count:
Address:
Protein:
Glucose:
Phone number:
Fax number:
Major clinical findings, travel history, treatment & date given (please include vaccine history)
Do not fill out below this line
Report of State Laboratory Investigation
Neisseria meningitidis
DNA detected by PCR
Streptococcus pneumoniae
DNA detected by PCR
Streptococcus pneumoniae
Serogroup B
DNA not detected by PCR
Streptococcus pneumoniae
Serogroup C
PCR not performed
Serogroup Y
Haemophilus influenzae
Serogroup undetermined
DNA detected by PCR
Neisseria meningitidis
Haemophilus influenzae
DNA not detected by PCR
DNA not detected by PCR
Neisseria meningitidis
Haemophilus influenzae
PCR not performed
PCR not performed
I
. --Please submit new sample.
NO EXAM MADE
NADEQUATE SPECIMEN FOR TESTING
Comments
Disclaimer: This test was developed and its performance characteristics determined by the Microbial Diseases Laboratory of the California Department of Public Health.
It has not been cleared or approved by the U.S. Food and Drug Administration.
Date reported
Report approved by
MDL-VPP-Form01 (7/16)