Form SRD-1 "Request for Immunological/Isolation Services-Viral Testing Unit" - New Jersey

What Is Form SRD-1?

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

Form Details:

  • Released on October 1, 2017;
  • The latest edition provided by the New Jersey Department of 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 printable version of Form SRD-1 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form SRD-1 "Request for Immunological/Isolation Services-Viral Testing Unit" - New Jersey

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New Jersey Department of Health
State Lab Specimen ID No.
Public Health and Environmental Laboratories
PO Box 361
Trenton, NJ 08625-0361
REQUEST FOR IMMUNOLOGICAL / ISOLATION / MOLECULAR TESTING SERVICES
Enter all information legibly and completely to avoid processing delays!
Name (Last, First, MI)
(NOTE: Name on each specimen must exactly match the name on this form.)
CDS Case Number
Address (Street, Apt. #)
City
State
Zip Code
Gender
DOB
FOR PHEL USE ONLY: Applicable Test
Date/Time Received
Male
/
/
Female
Specimen Type
Serum
Throat Wash
Stool
Amniotic Fluid
Biopsy/Autopsy
Plasma (EDTA)
Bronchoalveolar Lavage/Wash
CSF
Sputum
Fixed Tissue (Specify):
Nasal Wash
Swab
Frozen Tissue (Specify):
Urine
Lesion/Vesicle Aspirate
Other:
NOTE: Zika testing on urine, CSF, and/or amniotic fluid must be accompanied by a serum specimen.
Symptom Onset Date
Pertinent Clinical Information (brief history, clinical findings, relevant lab data)
Tests Requested
Viral Serology Screens
Current Infection/Outbreak Investigation
Zika Testing
90420
Rubella (German Measles) IgG
90435
Rubeola IgM
80080/82/84
Zika Panel (PCR,IgM)
90430
Rubeola (Measles) IgG
90565
Cytomegalovirus IgM
80092/94
PCR Only
90440
Mumps IgG
90575
Toxoplasmosis IgM
80020/50/60
Newborn
90550
Varicella IgG
80090
Follow Up IgM
Hepatitis Testing
90560
Cytomegalovirus IgG
80050/65
Amnio & Serum PCR
90610
Hepatitis A IgM Antibody
90570
Toxoplasmosis IgG
90611
Hepatitis A Total Antibody
90600
Herpes Group IgG
Other: Specify
90630
Hepatitis B Surface Antigen
Viral Isolation Testing
90640
Hepatitis B Surface Antibody
___________________
90710
HSV
90650
Hepatitis B Total Core Antibody
___________________
Molecular/PCR
90660
Hepatitis C Antibody
___________________
90798
Influenza
WNV Testing
95205
Respiratory Virus Panel
80001
WNV IgM Antibody
90800
MERS CoV
80005
WNV IgM-CSF
90787
Norovirus
Specimen Collection Date and Time
/
/
_____:_____
AM /
PM
Date:
Time:
(MUST BE COMPLETED BY SUBMITTING FACILITY)
Requesting Physician Information (PRINT)
Submitting Facility/Laboratory Information (PRINT)
Physician Name (Print or Type)
Facility Name (Print or Type)
Address (Street and Suite, City, State, Zip Code)
Address (Street and Suite, City, State, Zip Code)
Contact Name
Contact Name
Contact Telephone No.
Contact Fax No.
Contact Telephone No.
Contact Fax No.
Email Address
Patient ID Number
Email Address
Patient ID Number
See Instructions for SRD-1 Form
SRD-1
OCT 17
New Jersey Department of Health
State Lab Specimen ID No.
Public Health and Environmental Laboratories
PO Box 361
Trenton, NJ 08625-0361
REQUEST FOR IMMUNOLOGICAL / ISOLATION / MOLECULAR TESTING SERVICES
Enter all information legibly and completely to avoid processing delays!
Name (Last, First, MI)
(NOTE: Name on each specimen must exactly match the name on this form.)
CDS Case Number
Address (Street, Apt. #)
City
State
Zip Code
Gender
DOB
FOR PHEL USE ONLY: Applicable Test
Date/Time Received
Male
/
/
Female
Specimen Type
Serum
Throat Wash
Stool
Amniotic Fluid
Biopsy/Autopsy
Plasma (EDTA)
Bronchoalveolar Lavage/Wash
CSF
Sputum
Fixed Tissue (Specify):
Nasal Wash
Swab
Frozen Tissue (Specify):
Urine
Lesion/Vesicle Aspirate
Other:
NOTE: Zika testing on urine, CSF, and/or amniotic fluid must be accompanied by a serum specimen.
Symptom Onset Date
Pertinent Clinical Information (brief history, clinical findings, relevant lab data)
Tests Requested
Viral Serology Screens
Current Infection/Outbreak Investigation
Zika Testing
90420
Rubella (German Measles) IgG
90435
Rubeola IgM
80080/82/84
Zika Panel (PCR,IgM)
90430
Rubeola (Measles) IgG
90565
Cytomegalovirus IgM
80092/94
PCR Only
90440
Mumps IgG
90575
Toxoplasmosis IgM
80020/50/60
Newborn
90550
Varicella IgG
80090
Follow Up IgM
Hepatitis Testing
90560
Cytomegalovirus IgG
80050/65
Amnio & Serum PCR
90610
Hepatitis A IgM Antibody
90570
Toxoplasmosis IgG
90611
Hepatitis A Total Antibody
90600
Herpes Group IgG
Other: Specify
90630
Hepatitis B Surface Antigen
Viral Isolation Testing
90640
Hepatitis B Surface Antibody
___________________
90710
HSV
90650
Hepatitis B Total Core Antibody
___________________
Molecular/PCR
90660
Hepatitis C Antibody
___________________
90798
Influenza
WNV Testing
95205
Respiratory Virus Panel
80001
WNV IgM Antibody
90800
MERS CoV
80005
WNV IgM-CSF
90787
Norovirus
Specimen Collection Date and Time
/
/
_____:_____
AM /
PM
Date:
Time:
(MUST BE COMPLETED BY SUBMITTING FACILITY)
Requesting Physician Information (PRINT)
Submitting Facility/Laboratory Information (PRINT)
Physician Name (Print or Type)
Facility Name (Print or Type)
Address (Street and Suite, City, State, Zip Code)
Address (Street and Suite, City, State, Zip Code)
Contact Name
Contact Name
Contact Telephone No.
Contact Fax No.
Contact Telephone No.
Contact Fax No.
Email Address
Patient ID Number
Email Address
Patient ID Number
See Instructions for SRD-1 Form
SRD-1
OCT 17
INSTRUCTIONS FOR COMPLETING THE SRD-1 FORM
REQUEST FOR IMMUNOLOGICAL/ISOLATION/MOLECULAR TESTING SERVICES
For All Requests:
For Viral Isolation:
Complete a separate form for each patient.
Collect specimens aseptically as soon as
possible after symptom onset or at autopsy.
Provide all information requested on the form.
Label each specimen with patient identification
Specimens may be rejected and testing will be
information, type of specimen, and date of
delayed if information is missing, incomplete, or
collection. Refrigerate specimens immediately
inaccurate.
and deliver to the New Jersey Department of
Please include additional patient information as
Health,
Public
Health
and
Environmental
warranted in the “Pertinent Clinical Information”
Laboratories (PHEL) as soon as possible. Ship
box on the form, e.g., brief history, clinical
on cold or frozen cold packs with next day
findings, relevant lab data, etc.
delivery.
Specimens should be labeled with two (2) identifiers,
For Viral Serology:
i.e., Name (which must match photo ID), DOB, other
unique patient ID.
Collect acute specimen via venipuncture into
appropriate tube (red top, serum separator)
Specimen and SRD-1 identifiers must match. (Name
within 7 days of onset. Convalescent samples
on the specimen must EXACTLY match the name on
should be drawn similarly 14 to 21 days after
the form.)
the acute sample. Allow blood to clot before
centrifuging to separate the serum. Store sera
For Zika Testing:
at 2 °C to 8 °C (35.6 °F to 46.4 °F) until they
For newborn specimen requirements contact the
are shipped to the Lab. If specimen will not be
Communicable Disease Service at 609-826-5964
delivered to the lab within 7 days, freeze serum
For all others:
samples at –20 °C (-4 °F).
Ship refrigerated
3 ml of serum and 3 ml of urine are required
specimens
on
cold
packs,
and
frozen
specimens on dry ice for next day delivery.
Zika specimens collected and shipped Monday—
Thursday
For Molecular/PCR:
o
Refrigerate serum and urine at 2-8
C
Norovirus Testing
Ship on frozen cold packs within 24 hours of
Should not be frozen, only refrigerated. Do
collection
not add fixatives or preservatives.
Follow IATA Packaging Instructions for Category B
Infectious substances
Influenza, Respiratory Virus Panel, and MERS
CoV Testing
If shipment cannot occur within 24 hours, freeze at
o
Collect respiratory specimens aseptically
–15 to –25
C and ship overnight on dry ice
as soon as possible after symptom onset or
Zika specimens collected Friday through Sunday
at autopsy.
Label each specimen with
o
Freeze serum and urine at –15 to –25
C
patient identification information, type of
Ship Monday on dry ice
specimen,
and
date
of
collection.
Refrigerate
samples
immediately
and
Follow IATA Packaging instructions for Category B
deliver to the PHEL as soon as possible.
infectious substances and dry ice
Maintain cold chain throughout delivery
For more information on PHEL Zika Testing go to:
process.
If delivery will be delayed,
http://www.nj.gov/health/phel/
specimens should be frozen at –20 ° C.
Ship refrigerated specimens on cold packs,
and frozen specimens on dry ice for next
day delivery.
Delivery:
Ground deliveries should be made to:
New Jersey Department of Health
Public Health and Environmental Laboratories
Specimen Receiving Unit
3 Schwarzkopf Drive
Ewing, NJ 08628
http://www.state.nj.us/health/forms/srd-1_instr1.pdf
Directions at:
http://www.state.nj.us/health/forms/srd-1_instr2.pdf
Map at:
SRD-1 (Instructions)
OCT 17
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