Quantiferon-TB Gold

Centralized Core Laboratory - Summa Akron City Hospital : Send Out

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:

Hospital:

Test ID :

QUTBG

Test Workstation :

SUMMA

Specimen Type:

Whole Blood

Tube Type:

Please contact Sendouts 330-543-8570 or 330-543-8571 for collection kit; special tubes required for this assay: Grey (Quantiferon NIL) top tube, Green (Quantiferon TB1) top tube, Yellow (Quantiferon TB2) top tube, Purple (Quantiferon Mitogen) top tube.

Collection Volume:

4- 1 mL tubes

Cause for Rejection:

If specimens are not collected and processed according to the collection procedure, refrigerated, frozen, or QNS specimen.

Storage:

Ambient

Availability:

Sent to Reference Lab

Methodology:

Lymphocyte Stimulation with ELISA

Special Instructions:

Specimen Collection Procedure: (Call lab for special tubes) 1. Draw four tubes in the following order: Grey,then Green,then Yellow,then Purple top tube. Important: Gray tube first. 2. The tubes are vacuumed to only accept 1 mL. Tubes fill slowly so keep tube on the needle for 23 seconds after tube appears to have completed filling (up to the black line). 3. When tubes are filled shake VIGOROUSLY AND MAKE SURE THE INSIDE OF THE TUBE IS COATED WITH BLOOD for 1012 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. 5. It is preferred that the specimen is drawn the morning of testing and received in Akron Childrens lab by 10:00 AM.

Lab/Phone:

330-543-8418

TAT:

48 hours

Additional Info:

Reference range available on patient report.

CPT Code:

86480