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. Acid Fast Culture   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Acid Fast Culture
CPT Code: 87116

Specimen Type: Sputum, BAL, Gastric aspirate, Urine, Tissue, CSF, Blood or Bone Marrow, Stool, Throat swab (ESwab) if unable to obtain sputum

Tube Type/Collection Container: Specimen container, Isolator tube (blood or bone marrow)

Collection Volume: Sputum:5-10 mL Blood or Bone Marrow: 1.5 mL in Isolator tube Gastric asp.: 5.0 mL or greater Urine: First void 25-50 mL BAL: 1.0 mL or greater

Cause for rejection: Specimen sent in nonsterile container. Sputum specimen consisting of all saliva. Specimens with insufficient volume will be rejected.

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Fluorescent Antibody Stain for AFB, Culture for AFB

TAT: AFB stain: 24 hours; AFB culture: 8 weeks


Lab/Phone: 330-543-8412

Additional Info: Physician will be notified of positive stains and/or cultures

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: