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. Influenza A/B Ag   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Influenza A/B Ag
CPT Code: 87804(x2)

Specimen Type: 1 FLOCKED NPH swab or Nasal Washings

Tube Type/Collection Container: Culturette or Specimen container

Collection Volume: 1 NPH swab. Send swab in culturette. We recommend a second NPH swab in M4 viral transport medium in case follow-up testing may be required. Alternate specimen: Nasal wash: 1.5 mL wash in sterile container

Cause for rejection: Specimen dry, non- sterile container or incorrect swab ( do not use NPH wire swab), QNS.

Storage: Refrigerated

Availability: Daily 24/7

Methodology: Immunofluorimetric Assay

Special Instructions: NPH swab in culturette or Nasal wash used for Rapid Influenza test. Testing no longer automatically reflexes to Respiratory Virus Isolation. A second NPH flocked swab, broken off in M4 must be submitted along with a separate order for RVI requests. RVI's are not performed on specimens that are positive by the Rapid Influenza Ag test. A negative result does not rule out viral infection. Positive results will be called.

TAT: 2 hours


Lab/Phone: 330-543-8576

Additional Info: Reference range: Influenza A / B Ag: Negative

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: