Forms for the Infectious Disease Laboratory

On this page:
Submission and Testing Forms
COVID-19 Special Request Forms
Antibiotic Resistance (AR) Laboratory Network
Special Projects/Other Forms
CDC Select Agent Forms
Instructions, Helpful Hints, and Feedback

Submission and Testing Forms

All forms are printable and fillable and optimized for Internet Explorer, Chrome, or Adobe. Forms will be updated often to add functionality, please bookmark this page to use most current version.

• General Infectious Disease Laboratory Submission Form (PDF)
  General Submission Form Guidance (PDF)
  


• COVID-19 Testing (2618) Submission Form (PDF)
  Required for diagnostic COVID-19 submissions (will receive results)
  COVID-19 Submission Form Guidance (PDF)


• COVID-19 Special Request (2621) Submission Form (PDF)
  
  Required for COVID-19 variant surveillance, positive hospitalized patients, suspected reinfection, vaccine breakthrough, and monoclonal antibody failure (will not receive results)
  COVID-19 Special Request Form Guidance (PDF)


• Influenza Hospitalized Surveillance (1492) Submission Form (PDF)
  Required for persons hospitalized with influenza-like illness, clinical suspicion of influenza, or deceased following influenza-like illness. Combined influenza/COVID-19 multiplex assay is used for this surveillance.
  Influenza Surveillance Form Guidance (PDF)


• Influenza Non-hospitalized Surveillance (493) Submission Form (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 Surveillance Form Guidance (PDF)

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Antibiotic Resistance (AR) Laboratory Network

Forms

• ARLN Submission Form (PDF)
• CRO Isolate – Supplemental Submission Form (PDF)

Sampling and Handling Guidance

• Candida auris Sampling and Handling Guidance (PDF)
• Carbapenem Resistant Organism (CRO) Sampling and Handling Guidance (PDF)

Supplies

• MDH AR Laboratory Supply Form (Order Supplies, Boxes, Kits from MDH)

Contact arlnmn@state.mn.us for questions, specimen handling, or free-of-charge shipping information.


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Other MDH Forms

• Laboratory Supply Order Form (Mailers, Supplies, Boxes, Kits)
  
• Rabies Submission Form (PDF)

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CDC Forms

• 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

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Instructions, Helpful Hints and Feedback

Instructions

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.

Helpful Hints

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.

Feedback

Please submit comments or problems with MDH-PHL forms by email to health.mdhlab@state.mn.us. We would like to hear feedback so that we can make these forms as user friendly and functional as possible.

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