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. RSV Antigen Detection   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for RSV Antigen Detection
CPT Code: 87807

Specimen Type: 1 FLOCKED NPH swab or Nasal Washings

Tube Type/Collection Container: Culturette or Specimen Container

Collection Volume: 1 Flocked NPH swab. Send swab in culturette. Alternate Specimen: 1.5 mL wash in sterile container.

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

Storage: Refrigerated

Availability: Daily

Methodology: Immunofluorometric Assay

Special Instructions: NPH swab in culturette or Nasal wash used for Rapid RSV test. Testing no longer automatically reflexes to Respiratory Virus Isolation (RVI). 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 RSV test. A negative result does not rule out viral infection. Positive results will be called.

TAT: 2 hrs.


Lab/Phone: 330-746-9623

Additional Info: Reference range: Repiratory Syncytial Virus ( RSV ) 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: