Forms for the Infectious Disease Laboratory
All forms are printable, fillable and optimized for Internet Explorer, Chrome, or Adobe. Forms will be updated often to add functionality, so please bookmark this page to use the most current version.
- COVID-19 Specimen Submission and Test Request Form (2618) (PDF)
Required for diagnostic COVID-19 submissions. You will receive results.
COVID-19 Form Guidance (PDF)
- COVID-19 Special Request Form (2621) (PDF)
Required for COVID-19 variant surveillance, positive hospitalized patients, suspected reinfection, vaccine breakthrough, and monoclonal antibody failure. You will not receive results.
COVID-19 Special Request Form Guidance (PDF)
- Influenza/COVID-19 Hospitalized Submission and Test Request Form (1492) (PDF)
Required for persons hospitalized with influenza-like illness, under clinical suspicion of influenza, or deceased following influenza-like illness. Combined influenza/COVID-19 multiplex assay is used for this surveillance.
Influenza Form Guidance (PDF)
- Influenza/COVID-19 Non-Hospitalized Submission and Test Request Form (493) (PDF)
Required for non-hospitalized individuals when requested by MDH epidemiology related to cluster investigation, other unusual circumstances, or for laboratory surveillance of seasonal strains. Combined influenza/COVID-19 multiplex assay is used for this surveillance.
Influenza Form Guidance (PDF)
See Antimicrobial Resistance (AR) Laboratory Network Lab Forms for AR forms.
Guidance for submitters
In the forms sent to the Minnesota Infectious Disease Laboratory, certain fields are required by the CDC’s Clinical Laboratory Improvement Amendments (CLIA). Please read the instructions for each form carefully.
Failure to provide required information will cause delays in testing while we contact the submitter for the missing information. Please be sure to check the forms before sending samples to make sure that all necessary information is provided.
Tips on submitter information
Since the Minnesota Department of Health-Public Health Laboratory (MDH-PHL) serves the entire state of Minnesota and beyond, it is important that the submitter information is complete:
- 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.
Conforming to both of these tips will assist MDH-PHL in getting results to the proper submitter.
Feedback
Please submit comments or problems with Minnesota Department of Health-Public Health Laboratory forms by email to health.mdhlab@state.mn.us. We welcome feedback so that we can make these forms as user-friendly and functional as possible.