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. Resp Virus Isolation   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Resp Virus Isolation
CPT Code: 87254

Specimen Type: Nasal washings, or FLOCKED NPH swab, Throat swab, sputum

Tube Type/Collection Container: Specimen container

Collection Volume: Nasal wash: 1.5 mL wash or sputum in viral transport medium (M4) Swabs: Flocked NPH swab or throat swab broken off into viral transport medium (M4)

Cause for rejection: Specimen not in viral transport medium (M4), dry, in non-sterile container or collected with incorrect swab ( do not use NPH wire swab), QNS.

Storage: Refrigerated

Availability: Daily (0800-1700)

Methodology: Spin-amplified shell vial culture with IFA stain to confirm

Special Instructions: Specimens in M4 must be sent on ice ASAP to lab. Specimens will be processed daily M-F if received in the Virology lab before 2:30 p.m. and if by 11:30 a.m. on Sat. and Sunday. Preliminary report issued at 48 hrs. Positive results called. Final report issued at 72 hrs. Failure to isolate virus in culture does not rule out viral etiology.

TAT: 48-72 hrs


Lab/Phone: 330-543-8576

Additional Info: Reference Range: Respiratory viral antigens: NEGATIVE ( Includes testing for RSV, Influenza A &B virus, Adenovirus, Human Metapneumovirus, and Parainfluenza 1,2 &3 viruses)

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: