Form 2a.

NTP Laboratory Request and Result Form

To be filled out by Health Worker

Name of Requesting Facility: ________________________________ Date of Request: ______________________

Facility Contact Information: ________________________________ Requesting Physician: __________________

Name of Patient: _________________________________________ Age: _________ Sex: [ ] M [ ] F

Address: _________________________________________________Patient’s Contact No.: __________________

Reason for History of Treatment: [ ] New If for Diagnosis or Baseline,

[ ] Diagnosis
Examination: [ ] Retreatment Registration Group:
[ ] Baseline [ ] New [ ] TAF
[ ] Relapse [ ] PTOU
TB Case No.: _______________
[ ] Follow-up [ ] TALF
For PMDT, month of treatment: __________

Specimen Type: [ ] Sputum Repeat Collection? [ ] No

[ ] Other (specify): _____________ [ ] Yes Reason: ____________

Date Specimen Collected: Specimen Date of Collection If for Xpert, DST or LPA:

1 Presumptive DS-TB [ ]

Test Requested: 2 Presumptive DR-TB [ ]

Test
Test Requested:
Requested: [ ] DSSM [ ] Xpert MTB/RIF [ ] Culture [ ] DST
If for Xpert, DST or LPA:
[ ] LPA
If for Xpert, DSSM Result: ___________ If for Presumptive
DST, Xpert Result: _____________
Drug-Susceptible TB
Test If for[ DST,
] HIV Result: ______________
Test Requested:
Requested:
Prepared by: ___________________________________________ Position: ____________________________
Presumptive Drug-Resistant TB
Signature over Printed Name
[ ]
Test Requested:
Portion below to be filled-out by Medical Technologist/Microscopist/Xpert Technician

If for Xpert, DST or LPA:

Test Requested: Date Received: ___________________________
Laboratory Serial Number: _______________________________ Presumptive Drug-Susceptible TB
Date Examined:
[ ] ___________________________

LABORATORY TEST Presumptive Drug-Resistant TB

FINDINGS [ ]
Smear Microscopy
Xpert MTB/RIF
Specimen 1 2*
If for Xpert, DST or LPA:
Visual Appearance**
Presumptive Drug-Susceptible TB
Reading [ ]

Laboratory Diagnosis Presumptive Drug-Resistant TB

[ ]
*Specimen 2 is not applicable for follow-up ** Muco-purulent, blood-stained, salivary, etc.

Performed by: _______________________________________________ Date of Release: ___________________________

** Muco-purulent, If
*Specimen 2 is not applicable for follow-up
Signature over Printed Name for Xpert, salivary,
blood-stained, DST or etc.
LPA:
Presumptive Drug-Susceptible TB
A separate result form for TB Culture,
*Specimen 2 is notDST and LPA
applicable will be issued.
for follow-up [ ]
** Muco-purulent, blood-stained, salivary, etc.

Presumptive Drug-Resistant TB
*Specimen 2 is notDST
applicable for follow-up [ ]
** Muco-purulent, blood-stained, salivary, etc.
A separate result form for TB Culture, and LPA will be issued.

*Specimen 2 is not applicable for follow-up ** Muco-purulent, blood-stained, salivary, etc.

A separate result form for TB Culture, DST and LPA will be issued. If for Xpert, DST or LPA: