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: 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 GENTLY AND MAKE SURE THE INSIDE OF THE TUBE IS COATED WITH BLOOD for 10-12 seconds. The shaking is extremely important as there are reagents in the tube. 4. Send immediately to the Centralized Core Lab (CCL). Tubes need processed no later than 16 hours after collection. CCL staff: send to SUMMA with a routine day shift courier during the week and call a STAT courier on weekends, holidays, and PM/MN shifts. 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 or order in Epic as a Miscellaneous Sendout Test (LAB3064) with Quantiferon to SUMMA.

TAT: 48 hours


Lab/Phone: 330-543-8418

Additional Info: Reference range available on patient report.

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Ingrid Hershey, Laboratory Administrative Director, at 330-543-8721.

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


Physician Signature: Date: