Form MDL-176 "Adult C. Botulinum Toxin Detection Laboratory Request and Final Report Form" - California

What Is Form MDL-176?

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 October 1, 2007;
  • 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-176 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-176 "Adult C. Botulinum Toxin Detection Laboratory Request and Final Report Form" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNA DEPARTMENT OF PUBLIC HEALTH
Microbial Diseases Laboratory
Tel (510) 412-3700
Fax (510) 412-3706
Adult C. botulinum Toxin Detection
Laboratory Request and FINAL REPORT FORM
Note: Submit specimens through the local public health laboratory with appropriate shipping labels and refrigerant. Advanced
approval of the case is required from the local public health epidemiologist and the Division of Communicable Disease Control Duty
Officer of the Day PRIOR to submission of specimens.
Submitting Lab Number
State Lab Number (L.S.#)
Patient's Name
Sex
Date of Birth
SS#
Medical Record #
Onset of Symptoms
Additional info
Is patient on medication known to interfere in the analysis?
□ YES
□ NO
(See list of Meds)
Specimen type
□ = Serum (□ Pre or □ Post-Antitoxin)
□ = Stool
□ = Gastric
□ = Tissue
□ = Implicated Food
□ = Other (
)
Comments:
Collection Date:
Time:
For additional patient information: Contact Dr._________________________
Fax (
)-
-
Phone (
)-
-
=========================================================================================
THIS SECTION FOR STATE LABORATORY USE ONLY
RECEIVED IN LAB (Date/Time)
By: (Initials)_________
Sample Integrity □ Acceptable
□ Unacceptable
□ Marginal
□ QNS □ Submit new specimen
Comments:
=========================================================================================
FINAL RESULTS
No Clostridium botulinum toxin detected.
Clostridium botulinum toxin, type______ detected.
No Clostridium botulinum organisms were detected.
Clostridium botulinum type______ organisms, were isolated.
Other Findings_________________________________________________________
UNSATISFACTORY SAMPLE: _____
_____________ __________________________
Analyst:
Date Reported:
Supervisory Review:
Date:
SUBMITTING LABORATORY
cc:
DCDC
Submitting PH Lab
MDL file
MDL-176/rev. Oct 2007
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNA DEPARTMENT OF PUBLIC HEALTH
Microbial Diseases Laboratory
Tel (510) 412-3700
Fax (510) 412-3706
Adult C. botulinum Toxin Detection
Laboratory Request and FINAL REPORT FORM
Note: Submit specimens through the local public health laboratory with appropriate shipping labels and refrigerant. Advanced
approval of the case is required from the local public health epidemiologist and the Division of Communicable Disease Control Duty
Officer of the Day PRIOR to submission of specimens.
Submitting Lab Number
State Lab Number (L.S.#)
Patient's Name
Sex
Date of Birth
SS#
Medical Record #
Onset of Symptoms
Additional info
Is patient on medication known to interfere in the analysis?
□ YES
□ NO
(See list of Meds)
Specimen type
□ = Serum (□ Pre or □ Post-Antitoxin)
□ = Stool
□ = Gastric
□ = Tissue
□ = Implicated Food
□ = Other (
)
Comments:
Collection Date:
Time:
For additional patient information: Contact Dr._________________________
Fax (
)-
-
Phone (
)-
-
=========================================================================================
THIS SECTION FOR STATE LABORATORY USE ONLY
RECEIVED IN LAB (Date/Time)
By: (Initials)_________
Sample Integrity □ Acceptable
□ Unacceptable
□ Marginal
□ QNS □ Submit new specimen
Comments:
=========================================================================================
FINAL RESULTS
No Clostridium botulinum toxin detected.
Clostridium botulinum toxin, type______ detected.
No Clostridium botulinum organisms were detected.
Clostridium botulinum type______ organisms, were isolated.
Other Findings_________________________________________________________
UNSATISFACTORY SAMPLE: _____
_____________ __________________________
Analyst:
Date Reported:
Supervisory Review:
Date:
SUBMITTING LABORATORY
cc:
DCDC
Submitting PH Lab
MDL file
MDL-176/rev. Oct 2007