Form LAB443 "Culture for Identification - Mycobacteria" - California

What Is Form LAB443?

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 August 1, 2001;
  • 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 LAB443 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 LAB443 "Culture for Identification - Mycobacteria" - California

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Microbial Diseases Laboratory
CU
LTUfri;E FOA
IDENTi
FiCATION-MYCOBACT
ERI
A
]
Patient's
name (last, first)
A£I€
Description of Specimen
Date
collectec
- -
Address
S<! t)4
Check
source:
OHuman
O
Animal
(species}
Physician's name
O
Other (speciiy}
Clinical condition
or
suspected disease
Date of onset
Checl< box which describes the specimen 1rom which the
submitted
culture
was
obtain
ed.
O
Case
O
Diagnostic
specim
en
O
Blood
O
Gastric
QSputum
OCSF
Return report to:
O
Th
roat
O
Urine
O
Feces
0
Skin
I
0
Tissue
(type):
Name
O
Pus (source}:
Address
O
Exudate
(source):
City/State1ZIP
O
_
W ound
(location}:
L
Submitter's
identification of organisf:7
·-
Was Tuberculin
skin
testing done?
OYes
ONo
Results:
OT
mm
PPD-B
mm
PPD-S
mm
PPD-G
mm
PPD-Y
mm
Other (speciiy):
IMPORTANT:
Enter your
laboratory
findings on reverse side.
X-ray
changes
present?
OYes
-
Chemotherapy
O
None
Types
Dosage
7H10
Colony
Morphology
Lowenstein Jensen
Cellular Morphology and Acid
Fastness:
Growth
35°
25°
30°
42°
Pigment:
in dark
in light
Niacin
Tween hydrolysis
Nitrate
reduction
Catalase:
68°
Quantity
Arylsulfatase:
3
day
2
week
Tellurite reduction change
MacConkev
aaar
Iron uptake
Date
received
LAB 443
(8/0
1)
~
Date
reported
ONo
Brief case history, therapy, outcome
Date
Dat1i
Begun
Compllited
· -
--
· -
DO NOT WRirE
BELOW THIS LINE
Report of
State
Laboratory Investigation
Urease
-
5% NaCl
Socium citrate
Inositol
Mannitol
Pyrazinamidase
Probe
HPLC
Pattern
Organism
identified as:
PHge
1
012
---
M OL- N-003
Microbial Diseases Laboratory
CU
LTUfri;E FOA
IDENTi
FiCATION-MYCOBACT
ERI
A
]
Patient's
name (last, first)
A£I€
Description of Specimen
Date
collectec
- -
Address
S<! t)4
Check
source:
OHuman
O
Animal
(species}
Physician's name
O
Other (speciiy}
Clinical condition
or
suspected disease
Date of onset
Checl< box which describes the specimen 1rom which the
submitted
culture
was
obtain
ed.
O
Case
O
Diagnostic
specim
en
O
Blood
O
Gastric
QSputum
OCSF
Return report to:
O
Th
roat
O
Urine
O
Feces
0
Skin
I
0
Tissue
(type):
Name
O
Pus (source}:
Address
O
Exudate
(source):
City/State1ZIP
O
_
W ound
(location}:
L
Submitter's
identification of organisf:7
·-
Was Tuberculin
skin
testing done?
OYes
ONo
Results:
OT
mm
PPD-B
mm
PPD-S
mm
PPD-G
mm
PPD-Y
mm
Other (speciiy):
IMPORTANT:
Enter your
laboratory
findings on reverse side.
X-ray
changes
present?
OYes
-
Chemotherapy
O
None
Types
Dosage
7H10
Colony
Morphology
Lowenstein Jensen
Cellular Morphology and Acid
Fastness:
Growth
35°
25°
30°
42°
Pigment:
in dark
in light
Niacin
Tween hydrolysis
Nitrate
reduction
Catalase:
68°
Quantity
Arylsulfatase:
3
day
2
week
Tellurite reduction change
MacConkev
aaar
Iron uptake
Date
received
LAB 443
(8/0
1)
~
Date
reported
ONo
Brief case history, therapy, outcome
Date
Dat1i
Begun
Compllited
· -
--
· -
DO NOT WRirE
BELOW THIS LINE
Report of
State
Laboratory Investigation
Urease
-
5% NaCl
Socium citrate
Inositol
Mannitol
Pyrazinamidase
Probe
HPLC
Pattern
Organism
identified as:
PHge
1
012
---
M OL- N-003
Submitt,
e r's Laboratory Findings
Cultures made from original clinicai sample were:
0
Pure
0
Mixed
If
mixed,
list other
organisms present: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
0
1-10
0
10-25
0
25-50
How many colonies
of
this
organism on primary isolation?
How frequently
has
this
organism been recovered?
D
Once only
0
2-5 times
O
Over 5
times
Was M. Tuberculosis ever
recovered from the patient
prior to this specimen?
OYes
Was the submitted organism
seen in stained smears made
directly from clinical
material?
ONo
OYes
ONo
0
Over 50
Medium
on
which
organism is being submitted: ___________________________________ _
Date inoculated:
__________
_
Conditions of incubation prior
to mailing:
Temperature:
Atmosphere: _ _ _ _ _ _
Indicate
in the chart
below the results of your laboratory
examinations of the
pure
culture
being submitted.
Colony
Morphology
7H10
Lowenstein Jensen
Cellular Morphology and Acid
Fastness:
Growth
35°
25°
30°
42°
Pigment:
in dark
in light
Niacin
Tween
hydrolysis
Nitrate reduction
Catalase:
68°
Quantity
Arylsulfatase:
3
day
2
week
Tellurite reduction change
MacConkey agar
Iron
uptake
Other tests or comments:
LAB
443 (8/01)
Urease
5%
NaC1
Socium citrate
Inositol
Mannitol
Pyrazinamidase
Probe
HPLC
Pattern
Organism
identified
as:
Pa,~e
2
of
2
,.
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