Infectious Disease Laboratory - Forms
- Instructions for Infectious Disease Testing and Submission Form (PDF:36KB/2 pages) (Revised October 2011)
- Printable Form (PDF:84KB/1 page) Print and fill out manually.
- Fillable Form (PDF: 578KB/1 page)Fill out and save on your computer, then print. (Revised January 2012)
Please note the four new REQUIRED questions on the bottom right corner of this form.
There is NO fee sticker required for influenza testing
- NEW Printable Hospitalized Influenza Form (PDF:107KB/1 page) Print and fill out manually. (Revised December 2011)
- NEW Fillable Hospitalized Influenza Form (PDF:793KB/1 page) Fill out on your computer, then print. (Revised January 2012)
- Hepatitis A Specimen Submission Form (PDF: 74KB/1 page)
- Hepatitis B Specimen Submission Form (PDF: 74KB/1 page)
- MDH Rabies Submission Form (PDF: 40KB/2pages)
- Request for MDH Laboratory Supply Materials form (PDF: 15KB/1 page)
- APHIS/CDC Form 4 - Report of Identification of a Select Agent or Toxin in a Clinical or Diagnostic Laboratory
INSTRUCTIONS, HELPFUL HINTS AND FEEDBACK
Certain fields are required by CLIA. Please read the instructions carefully. Failure to provide required information delays testing while we contact the lab for the missing information. Please be sure to check the forms before sending samples to make sure that all necessary information is provided.
Additional Helpful Hints:
Since MDH-PHL serves the entire State of MN and beyond it is important that the submitter information is COMPLETE. Please do not enter a facility acronym. If there are several clinics and/or hospitals with the same "system" name, please be sure to provide the city or other unique identifier to distinguish which facility is actually submitting the specimen and requesting the testing. Both of these tips will assist MDH-PHL in getting results to the proper submitter.
Feedback about forms:
Please submit comments or problems with the forms to the email address at the bottom of this page. We would like to hear feedback so that we can make these forms as user-friendly and functional as possible.