Department of Pathology
and Laboratory Medicine

Akron Children's Hospital
One Perkins Square
Akron, OH 44308
Laboratory
Ph: (330) 543-8573
Fax: (330) 543-3659

LABORATORY TEST REQUISITION


PATIENT INFO
Patient Name:
Medical Record #:
BD:        /        /              Sex:    F    M

PHYSICIAN INFO
Physician Name :
Address:
Ph: (        )        -              Fax: (        )        -              
Additional Report to:
Ph: (        )        -              Fax: (        )        -              

TESTS REQUESTED
Test Name: ICD9 Code: (required)
1. Quantiferon-TB Gold   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Quantiferon-TB Gold
CPT Code: 86480

Specimen Type: Whole Blood

Tube Type/Collection Container: Please contact Sendouts 330-543-8570 or 330-543-8571; special tubes required for this assay.

Collection Volume: 3- 1 mL tubes

Cause for rejection: If specimens are not collected and processed according to the collection procedure.

Storage: Ambient

Availability: Sent to Reference Lab

Methodology: Lymphocyte Stimulation with ELISA

Special Instructions: This is a scheduled test at Summa. Test must be scheduled with Summa Immunology prior to patient coming to lab to be drawn. Call Dr. Tom Alexander at 330-375-3719 to schedule. Specimen Collection Procedure: 1. Draw three tubes gray, red, purple per patient. Important Gray tube first then the other two in no particular order. 2. The tubes are vacuumed to only accept 1 mL. Tubes fill slowly so keep tube on the needle for 2-3 seconds after tube appears to have completed filling. 3. When tubes are filled shake VIGOROUSLY for 10-12 seconds. The shaking is extremely important as there are reagents in the tube. Please make sure and shake the tubes vigorously if they are not the test will not work. 4. Send immediately to the Immunology lab. Tubes need processed no later than 16 hours after collection. It is preferred that the specimen is drawn the morning of testing and received in Akron Childrens lab by 10:00 AM. Please send orders on a manual test requisition.

TAT: 48 hours


Lab/Phone: 330-543-8418

Additional Info: Reference range available on patient report. Immunology runs this assay every other Wednesday. Please call Sendouts at 330-543-8570 or 330-543-8571 for assay schedule.

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Cindy Maurer at (330)543-8689.

SHIP TO:
Department of Pathology and Laboratory Medicine
CCL
Akron Children's Hospital
One Perkins Square
Akron, OH 44308


Physician Signature: Date: