Sample Container Order Form Public Health Laboratory

Sample Container Order Form

DOCTOR/CLINIC/FACILITY NAME (PLEASE PRINT CLEARLY) DATE

SHIPPING ADDRESS CITY POSTAL CODE

NAME (PLEASE PRINT CLEARLY) AUTHORIZED SIGNATURE EMAIL TELEPHONE NO.

Sample Containers

Instructions on sample collection and submission can be found in the eLab Handbook: http://www.elabhandbook.info/PHSA/Default.aspx.

NOTE: EACH* CONSISTS OF (1) SAMPLE CONTAINER, (1) SAMPLE BAG & (1) REQUISITION/FORM UNLESS SPECIFIED

PLEASE DO NOT ORDER IN PADS, BAGS, PACKS, FLATS, TRAYS, BOXES OR CASES (Unless ordering the Serology Screening Requisition in the 50-page pad).

EACH*

CONTAINER TYPE / TEST DESCRIPTION TESTING INFORMATION AND FURTHER DETAILS No.

SWABS

APTIMA NUCLEIC ACID

TESTING (NAT) SWAB

Aptima Unisex Swab Sample Collection Kit

for Endocervical and Male Urethral Swab

specimens (purple label)

Chlamydia trachomatis AND Neisseria gonorrhoeae for Nucleic Acid Testing (NAT).

Trichomonas vaginalis for Nucleic Acid Testing (NAT) in females only.

Aptima Multitest Swab Sample Collection

Kit (suitable for vaginal, throat, rectal, eye

collection) (orange label)

APTIMA NUCLEIC ACID

TESTING (NAT) URINE

Aptima Urine Sample Transport Kit

(yellow label)

BACTERIAL CULTURE SWAB COPAN (green-top) eSwab + Liquid Amies Culture for bacterial pathogens excluding Mycobacterium spp.

Culture and polymerase chain reaction (PCR) test for Bordetella pertussis

Culture of urethral & eye specimens for Neisseria gonorrhoeae

INFLUENZA / OTHER

RESPIRATORY VIRUSES,

MEASLES and MUMPS

COPAN (red-top) + Universal Transport Media

Nucleic Acid Testing (NAT) for nasal/nasopharyngeal and throat specimens.

Do not use for Chlamydia trachomatis testing

VIRUS ISOLATION SWAB,

HERPES and VZV

COPAN (blue-top) + Universal Transport Media

Nucleic Acid Testing (NAT) for skin and genital specimens.

Do not use for Chlamydia trachomatis testing

BLOOD

TUBES

BLOOD PARASITES

K2EDTA (EDTA/Lavender top) vacutainer

(Malaria ) Smears to be submitted in addition to blood in EDTA

HEPATITIS C PCR Specimen to be submitted in EDTA vacutainer tube

SEROLOGY SCREENING

Serum separator tube (SST/Gold top)

vacutainer

Hepatitis, HIV, Prenatal, Rubella, Helicobacter pylori, Syphilis, Virus Serology

ZOONOTIC DISEASES &

EMERGING PATHOGENS

ASOT, AntiDNase B, Brucella, Borrelia, Coccidioides, Diphtheria, Tetanus, Toxoplasma,

Tularemia, Parasitic Serology, Bartonella, Cryptococcus, Referred Bacterial, Fungal

& Parasitic Testing, Arboviruses (West Nile virus), Hantavirus, Rickettsia, Ehrlichia/

Anaplasma, Leptospira, Referred Testing

OUTBREAK

KITS

GASTROINTESTINAL

DISEASE OUTBREAK KIT

Kit consists of 6 sterile vials for feces, 2 sterile vials for vomitus, 8 biohazard bags, 8 GI Outbreak Requisition and 1 GI Outbreak Fax

Notication form

INFLUENZA LIKE ILLNESS

OUTBREAK KIT

Kit consists of 6 swabs, 6 biohazard bags, 6 VI

requisition forms

FOR FACILITY TESTING ONLY

(Maximum order per season is 50 kits. Orders over 50 kits must be approved

by the Virology Section).

FECES

VIALS &

PADDLES

ENTERIC PATHOGENS

PARASITOLOGY SAF (preservative) vial Orders must be approved by the Parasitology Section

PINWORM Pinworm sticky paddle Orders must be approved by the Parasitology Section

VIROLOGY Gastrointestinal virus testing (including Norovirus, Adenovirus, Astrovirus, Rotavirus

and Sapovirus)

BOTTLES

PLASTIC BOTTLES Sterile, 250 mL, treated with sodium

thiosulfate

Water Bacteriology (drinking water, raw water, recreational water)

SLIDES

MICROSCOPIC EXAM Gonorrhea, Bacterial Vaginosis & Yeast

SYPHILIS Dark Field/Direct Fluorescent Antibody

VIALS

AND

JARS

ENDOTOXIN-FREE VIALS 50 vials (yellow cap)/order (no requisition) Endotoxin/Limulus Amoebocyte Lysate (LAL) testing

FOOD MICROBIOLOGY JAR Sterile, 500 mL Food Quality and Food Poisoning Samples

TISSUE PARASITES Sterile vial

ICE PLASTIC JAR Sterile, 500 mL, treated with sodium

thiosulfate

Water Bacteriology (ice samples)

TUBERCULOSIS PLASTIC

JAR

Sputum, urine & other body uids (all Mycobacteria)

TUBERCULOSIS TREATED

GLASS JAR

Stomach washings (all Mycobacteria) (Request these prepared jars 2 weeks in

advance)

ZOONOTIC DISEASES &

EMERGING PATHOGENS

Helicobacter pylori Stool Antigen

REQUISITION ONLY ORDER

SEE REVERSE FOR LIST OF FORMS

REQUISITION CODE**

ADDITIONAL REQUESTS (Indicate)

NO. REQUESTED

SEE REVERSE SIDE FOR ADDITIONAL INFORMATION. VISIT OUR WEBSITE FOR INFORMATION ON COLLECTION PROCEDURES.

Form DCQM_Q07_4101F 1.00 Version 4.1 08/2023

Orders will be processed and mailed using Canada Post. Allow 5-14 business days for arrival.

For RUSH orders, provide the following information:

Courier Name: ________________________ Courier Account #: ____________________

Public Health Laboratory

655 West 12th Avenue, Vancouver, BC V5Z 4R4

www.bccdc.ca/publichealthlab

PHSA 302

Submit Form

ORDERING INFORMATION:

What should I order?

For instructions on what container to use and how to collect and submit the sample please consult the BCCDC Public Health Laboratory eLab

Handbook at http://www.elabhandbook.info/PHSA/Default.aspx.

How do I order?

Using this Sample Container Order Form please either email the request to [email protected] OR fax request to (604) 707-2606

• Please order in single units;

• Please DO NOT order in pads, bags, packs, ats, trays, boxes or cases (unless ordering the Serology Screening requisition which is available in

a 50-page pad).

How many should I order?

When ordering please keep in mind the following:

• A lot of sample containers have components that have a short shelf-life and therefore have expiry dates. Please order according to your

needs instead of "stock-piling".

When will I receive my order?

Orders will be processed and mailed using Canada Post. Please allow 5-14 business days for arrival.

For RUSH orders, provide the following information:

Courier Name: __________________________________________________________ Courier Account #: _____________________________

REQUISITION FORMS

Form DCQM_Q07_4101F 1.00 Version 4.1 08/2023

BAM

Bacteriology & Mycology Requisitions

2 sided form:

Side 1 – Specimens for Bacteriology and Mycology testing

Side 2 – Isolates for Identication

FP1

Food Poisoning Form Part A - Incident Summary

To be lled out during a food poisoning event

FP2

Food Poisoning Form Part B - Requisition

To accompany clinical and food/environmental samples in

suspected food poisoning events. Food Poisoning Form Part A -

Incident Summary must also be lled out.

Food Quality Sample Requisition

To accompany food samples submitted by Environmental Health

Ocers under the Food Quality Check Program

GIOB

Gastrointestinal Disease Outbreak Requisition

To accompany each sample submitted for GI outbreak

investigation

GIOF

Gastrointestinal Disease Outbreak Fax Form

To be lled out for each GI outbreak

PARA

Parasitology Requisition

Ova & Parasites, Blood & Tissue Parasites, Parasite Identication

(arthropods, worms, proglottids)

SER

Serology Screening Requisition

High volume serology testing; available in 50-page pad

Mycobacteriology/TB Requisition

Mycobacteriology testing

Virology Requisition

Non-serological virology testing

Water Bacteriology Requisition

Public health water analysis (drinking water, recreational and

waste water)

ZEP

Zoonotic Diseases & Emerging Pathogens Requisition

Serological, molecular and other testing for viruses, bacteria,

parasites and fungi

PHSA 302