with Instructions on Filling out the Laboratory Request Form

DEPARTMENT OF HEALTHRESEARCH INSTITUTE FOR TROPICAL MEDICINEAlabang, Muntinlupa City, Metro Manila(02) 8072628 to 32www.ritm.gov.phHospital WWW No.:LABORATORY TEST REQUEST FORMAccession No.:I. PATIENT INFORMATION: (To be filled-out by requisitioner)Name: (First, Middle, Last)WWW.RITM.GOV.PHDate of Birth:(MM/DD/YYYY)Address: (Street, Barangay. District, Municipality, Province, Region)☐ OPD ☐ ReferralLocation/ Classification:Date of Admission:(MM/DD/YYYY)☐ AS ☐ RITM INPATIENT ____________Clinical Impression: Suspected Agent: Date of Onset of Illness:(MM/DD/YYYY)Gender: ☐ M☐ FAge:(YY.MM)II. REQUISITIONER INFORMATION: (To be filled-out by requisitioner)Requisitioner (MD)/DiseaseSurveillance Officer (DSO) Name:Name of DiseaseReporting Unit (DRU):Type ofDRU:Address:Region: Province: Municipality:Requisitioner MD/DSO/DRU Contact Details:(at least 1)Tel No.: _________________________________Fax No.:_________________________________Cell No.: ________________________________Email Address: ___________________________III. HOSPITAL INFORMATION: (To be filled-up by RITM staff)Date and Time of Specimen Receipt:(MM/DD/YYYY- HR:MIN)Received by:printed name & signatureOfficialReceipt No.IV. SPECIMEN INFORMATION AND LABORATORY TESTS: (To be filled-out by requisitioner. Please mark <strong>with</strong> an “X” the box of the requested examination<strong>with</strong> additional information as requested. For pre-collected specimens, requisitioner to indicate the date and time of sample collection at the space provided.)LABORATORY EXAMINATIONInfluenza A H5N1 PCRInfluenza A H7N9 PCRMERS Coronavirus PCRpanCoronavirus PCRInfluenza A PCR and subtypingfor H1N1, H3N2 and H1N1 pdm09Influenza B PCRRSV PCRAerobic Culture and SensitivityAtypical pneumonia PCRLegionella, Mycoplasma and ChlamydophilaInvasive Bacterial Diseases PCRS. pneumo, H. influ and N. meningitidesElectron MicroscopyHistopathological ExaminationNPS and/orOPS in VTM(specify if NPSand/or OPS)NPS inAPTMSputumSerumSPECIMEN TYPERespiratoryspecimen(specify type)Fixed tissue(specify type, site &surgical procedure)Bloodin BHIOthers(specify type)Others: (Refer to RITM Lab Menu)Date and Time Collected:Collected by:RITM Staff OnlySpecimen Acceptable?☐ YES☐ NO____________☐ YES☐ NO_______☐ YES☐ NO______☐ YES☐ NO_______☐ YES☐ NO_________☐ YES☐ NO________________☐ YES☐ NO______☐ YES☐ NO___________

DEPARTMENT OF HEALTHRESEARCH INSTITUTE FOR TROPICAL MEDICINEAlabang, Muntinlupa City, Metro Manila(02) 8072628 to 32www.ritm.gov.phWWWIMPORTANT INSTRUCTIONS ON FILLING OUT THE LABORATORY TEST REQUEST FORMWWW.RITM.GOV.PHThe highlighted fields in the sample Laboratory Test Request Form below are the MINIMUM REQUIREDINFORMATION to be filled out. Failure to provide these minimum required information may result inspecimen rejection and delay in specimen processing.Information to be filled out by RITMStaff. Please leave these fields blank.At least one contact informationrequired for specimen to beconsidered as acceptable at RITM.Information in this section to befilled out by RITM Staff. Please leavethese fields blank.Fill out the specimen types matrix asshown in this sample form. Mark<strong>with</strong> “X” for collected specimens andthe requested information; leaveblank if no specimen was collected.Specify if NPS only, OPS only or acombination of NPS and OPS.Specify site and procedure for fixedtissues.Indicate date and time of collectionand name of staff collecting thespecimen.