Form LAB446 (MDL-N-11) "Bacterial Culture for Identification" - California

What Is Form LAB446 (MDL-N-11)?

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 January 21, 2011;
  • 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 LAB446 (MDL-N-11) 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 LAB446 (MDL-N-11) "Bacterial Culture for Identification" - California

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California Department of Public Health
Microbial Diseases Laboratory
850 Marina Bay Parkway, MS E-164
Richmond CA 94804
Submission of Bacterial Cultures for Identification
Instructions for Form MDL-N-11 (LAB 446)
Including Actinomyces-like organisms but excluding Mycobacteria
Record all the information applicable to the sample submitted on the submittal form MDL-N-11.
Please try to include more than the minimum requested details.
We are unable to process samples that do not contain adequate information.
The minimum information required includes the following.
Patient Demographics: Include the patient's name or other unique identifier, patient's age or date
of birth, patient's gender, suspected disease, and name ofrequesting physician.
Patient History: Include the diagnosis or disease suspected, onset date, acute symptoms,
treatment and outcomes, underlying or chronic conditions present, exposure/travel history (if
applicable), and contact history (if applicable).
Submitter Information: Include the submitters name and location
Sample Information: Include the sample source and~or type, date of collection, test requested and
suspected agent.
Cultural history (on form's reverse): Include the isolation method- in pure culture or in mixed
culture, the number of times that organism was isolated from this source and patient, other sources
from patient that yield the target organism, and how many times (if applicable) for each,
identification of all other organisms recovered, name of medium used, and inoculation date of
medium used.
Biochemical, Molecular, or Serological Testing ( on form's reverse): Include the names of all
tests used to determine the suspected identification of the sample.
Packaging and shipping: The shipper is responsible for making sure that all samples are
packaged and shipped according to the current federal and state packaging and shipping
regulations for Category A infectious substances and/or Category B diagnostic samples.
Send a young, actively growing subculture of your pure isolate.
Use a tubed solid agar medium that supports good organism growth and is labeled with the
patient's name or unique identifier and the date the tube was inoculated.
The preferred medium is without carbohydrates.
Do not submit Enterobacteriaceae on TSI slants.
For safety, all submitted culture tubes must have a tightened screw cap
secured in place using tape.
If you have questions regarding sample submission, call the MDL for guidance- 510-412-3700.
Before shipment, insert the completed Submittal Form MDL-N-11 between the inner metal
container and the outer cardboard container.
updated 1-21-2011
California Department of Public Health
Microbial Diseases Laboratory
850 Marina Bay Parkway, MS E-164
Richmond CA 94804
Submission of Bacterial Cultures for Identification
Instructions for Form MDL-N-11 (LAB 446)
Including Actinomyces-like organisms but excluding Mycobacteria
Record all the information applicable to the sample submitted on the submittal form MDL-N-11.
Please try to include more than the minimum requested details.
We are unable to process samples that do not contain adequate information.
The minimum information required includes the following.
Patient Demographics: Include the patient's name or other unique identifier, patient's age or date
of birth, patient's gender, suspected disease, and name ofrequesting physician.
Patient History: Include the diagnosis or disease suspected, onset date, acute symptoms,
treatment and outcomes, underlying or chronic conditions present, exposure/travel history (if
applicable), and contact history (if applicable).
Submitter Information: Include the submitters name and location
Sample Information: Include the sample source and~or type, date of collection, test requested and
suspected agent.
Cultural history (on form's reverse): Include the isolation method- in pure culture or in mixed
culture, the number of times that organism was isolated from this source and patient, other sources
from patient that yield the target organism, and how many times (if applicable) for each,
identification of all other organisms recovered, name of medium used, and inoculation date of
medium used.
Biochemical, Molecular, or Serological Testing ( on form's reverse): Include the names of all
tests used to determine the suspected identification of the sample.
Packaging and shipping: The shipper is responsible for making sure that all samples are
packaged and shipped according to the current federal and state packaging and shipping
regulations for Category A infectious substances and/or Category B diagnostic samples.
Send a young, actively growing subculture of your pure isolate.
Use a tubed solid agar medium that supports good organism growth and is labeled with the
patient's name or unique identifier and the date the tube was inoculated.
The preferred medium is without carbohydrates.
Do not submit Enterobacteriaceae on TSI slants.
For safety, all submitted culture tubes must have a tightened screw cap
secured in place using tape.
If you have questions regarding sample submission, call the MDL for guidance- 510-412-3700.
Before shipment, insert the completed Submittal Form MDL-N-11 between the inner metal
container and the outer cardboard container.
updated 1-21-2011
State of California-Health and Human Seivlces Agency
California Department of Public Health
BACTERIAL CULTURE FOR IDENTIFICATION
(Include Actinomyces-like Cultures; Exclude Mycobacteria Cultures)
Please print or type.
I
State Laboratory number
Patient's name (last, first)
tge
!Sex
Descriotion of Soecimen
Date collected
Address
Check source:
Physician's name
D
Human
D
Animal-species:
D
Other (specify):
Clinical condition or suspected disease
I
Date of onset
'
Origin of specimen:
D
Case
D
Epidemic
D
Sporadic
D
Contact
D
Carrier
D
Blood
D
Serum
D
Sputum
OCSF
Return report to:
·~
D
Throat
0 Urine
D
Feces
OSkin
<'
Name
r
7
Tissue, type:
Pus, source:
Address
Exudate, source:
Wound, location:
Other, specify:
ZIP code
.L----··
...
J
Submitters identification of organism
.
-··
... ,_ .... -··· ......
,
..
............... .....
·
......... .
-
......
··-
-
·--
...
-
.
..............
...
····-··-·-
.
....
···-·--· --····-·-· ·-···--··
..
·····-----
..
-
·-···-·-··--------
........
,
_______________
·--
··---··-···-·
Antimicrobial agents:
D
None
Types
Dosage
Date Begun
Date Completed
Important: Enter your laboratory findings an reverse.
Brief but complete case history, therapy, outcome (print or type)
Report of State Laboratory Investigation
DO NOT WRIT£
iN THIS
SP/i:c1:
KEY
Other tests or comments:
Organism Identified as:
A= acid
K= alkaline
S =
strong
Gr,
c
growth
NGr. = no growth
G= gas
• =
vial for gas .
detection
+
=
positive ·
negative
( ) =
number of days
blank= not done
LAB4-46 (11/07} (MDL-N-11)
Date received
I
Date reported
Microbial Diseases Laboratory • 850 Marina Bay Parkway, E164 • Richmond, CA 94804 • (510) 412-3700
Page 1 of 2
Submltter's Laboratory Findings
Cultures made from original clinical sample were:
D
Pure
D
Mixed
Jf mixed, list ·other organisms present: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Indicate colony count where applicable (e.g., urine): - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Number of times organ submitted:
(a) isolated from patient:. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
(b) transferred in the laboratory: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Medium(s) on whi~h primary growth was obtained: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Were stained smears or other preparations made directly from clinicaLJ71aterial?
0Yes
0No
If yes, was this organism seen?
0Yes
0No
Medium on which organism is being submitted: _________________________________ _
Date inoculated: _ _ _ _ _ _ _ _ _ _
Conditions of Incubation _prior to mailing: __ ....
!::.~2 . .
::~!~:.~:_- . . - . . . - . . _--_ . . _- _ _ _ - . . - . . _
.1
;r·· ...
Atmosphere: _____ _
Length: _ _ _ _ _
Indicate in chart below the results of your laboratory examinati'ons of the pure cultures being submitted using symbols given in the key:
A
=
acid
K
=
alkaline
S =
strong
Gr.
=
growtli
NGr.
=
no growth
Morphology
Gram stain
Catalase
Oxidase
Motility
KEY
Loeffler's
Pigmentation
Proteolysis
Pseudomonas
Agar
Gelatin Hydrolysis
Litmus Milk
Citrate (Simmons')
Indal
Urea Hydrolysis
Nitrates
V-P
Agglutination reactions
LAB 446 (11/07) (MOL·N-11)
G
=
gas
+
=
positive
negative
-....._( ) = nui;nber of days
blank
=
not done
. TSI:
Slant
Butt
H2S
Aesculin Hydrolysis
Falkow Lysine
Malonate
F
Phenylpyruvic Acid
p
Sodium Acetate
Moeller's Lysine
Decarboxvlase
Moeller's Arginine
Dihvdrolase
Moel ler's Orn1thine
Decarboxvlase
ONPG
KCN
..
Mucate
OF Medium
Open
+
Glucose
Closed ·
Other tests or·commenls
-
.
Hemolysis
Growth:
MacConkey Agar
SSAgar
Cetrimide Agar
25°C
35°c
42°c
Aerobically
CO2
Anaerobically
Nutri. Br. 0% NaCl
Nutri. Br. 3% NaCl
_.,
.
.
....
Base Used
Glucose
Levulose
Xylose
Lactose
Maltose
Sucrose
Raffinose
Adonitol
Dulcitol
Glycerol
Inositol
Mannitol
Sorbitol
Salicin
~
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