Forms for the Infectious Disease Laboratory
Clinical Testing and Submission Form
- Instructions for Clinical Testing and Submission Form (PDF)
(updated January 2017)
- MDH Submission Form: Printable (PDF) – Print and fill out manually.
- MDH Submission Form: Fillable (PDF) – Fill out and save on your computer, then print.
Hospitalized Influenza Testing and Submission Form
Influenza, Hospitalized Patients Only – There is only one form required.
Instructions – There are the four (4) required questions on the bottom right corner of this form, and see Instructions for Clinical Testing and Submission Form (PDF) to complete the rest of the form.
- Hospitalized Influenza Submission Form: Printable (PDF) – Print and fill out manually.
- Hospitalized Influenza Submission Form: Fillable (PDF) – Fill out on your computer, then print.
Special Projects/Other Forms
- MDH CRE Isolate – Supplemental Submission Form (PDF)
- MDH Rabies Submission Form (PDF)
- Request for MDH Laboratory Supply Materials form (PDF)
- MN Lab Specific CDC Specimen Submission Form
- CDC Specimen Submission Form with instructions
- CDC National Select Agent Registry Forms Home
- 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, so please read the instructions for each form 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.
Since MDH-PHL serves the entire state of Minnesota 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.
Please submit comments or problems with MDH-PHL forms by email to firstname.lastname@example.org. We would like to hear feedback so that we can make these forms as user friendly and functional as possible.