Supplies Order Form - Wisconsin State Laboratory of Hygiene

WISCONSIN STATE
LABORATORY OF HYGIENE
Madison Area # (608) 265-2966
Toll Free # 1-800-862-1088
Fax # (608) 890-2548
STATE LABORATORY OF HYGIENE
TEST REQUEST SHEET AND KIT ORDER FORM
AGENCY NAME:
SHIPPING
ADDRESS:
Revised May 27, 2014
DATE:
BILL TO#
AGENCY #:
PHONE #
CONTACT PERSON
Complete Kit
*Bulk
Container
or Media
Only
Kit Name/Number
Complete
Kit
*Bulk
Container
or Media
Only
Kit Name/Number
#3 Ova and Parasites
#22A HIV Blood Kit
#7 Diphtheria
#22C HIV Oral Swab-bulk only
#8 TB Sputum
#22H Hepatitis C PCR
#9 Neonatal Envelope 9 (for US
Mail/courier)
#27 Chlamydia/GC Urine BD
Viper
#213 Neonatal Screening Card
#29 Chlamydia/GC swabsFemale- BD Viper
#10 Stool Culture
#29M Chlamydia/GC swabs –
Male – BD Viper
#12 Cytology Body Fluid/ Non GYN
#29PR Chlamydia/GC swabs –
pharyngeal/rectal – Gen Probe
#13 Gastric TB
#29SCV Chlamydia/GC swabs –
Self Collected Vaginal – BD
Probetec Dry Swab
#16TP Thin Prep Pap Kit
#30 Pertussis (Bordetella)
#16TP Thin Prep Kit With Broom
#51 Rabies Shipper
#18 Virus/Chlamydia Culture
#51S Rabies Shipper Small
#22 Serology
#53 Invasive Bacti Survey
*
Bulk - kits without mailers/labels/sleeves
Container/Media only – no mailers, bags, or absorbents
Choice not available
MISCELLANEOUS
_______ ABS (Absorbent)
_______ BB (Biohazard bags 4”X6”)
_______ LBB (Large bio bag 5”X9”)
_______ PB (Pressure bag: 95kPa,
for liquid specimens only)
_______ KOOL (Small kool-it 4”X2”)
_______ LKOOL (Large kool-it 4”X4”)
_______ VL5 (5 ml vials)
_______EDTA (purple-top, 10mL)
_______SST (serum separator tube8.5mL)
_______ 30SO (Dacron/Wire Swab)
MAILERS AND LABELS
_______PAD (Padded envelope for #29SCV only)
_______ MS (MRS mailer AND sleeve)
_______ SV (cardboard sleeve only)
_______ MRS (small mailer) (2.5"x7"x2.5")
_______ MRM (medium mailer) (3"x5.75"x3.5")
_______ MRL (large mailer) (3.5"x7.5"x3.5")
_______ MRX (extra-large mailer (5"x7"x4")
_______ MRV (virus mailer) (11"x9.5"x11") (with
Koolit)
_______ ML (Mailing labels for kit #) _______
_______ ML (Mailing labels for kit #) _______
_______ ML (Mailing labels for kit #) _______
_______ UN3373 (Category B label)
TEST REQUEST FORMS AND BROCHURES
_______111 (Biochemical Genetics)
_______131 (Genetic Diagnosis)
_______132 (Neoplastic Diagnosis)
_______ CYT (Cytology #141)
_______ FP (WI FP Chlam/GC #3280)
_______ CDDA (Culture/Antigen #4105)
_______ CDDB (Serology/Antibody #4104)
_______ 4110 (Rabies Form)
_______ RABBRO (Rabies brochure)
_______ ORDFM (Supplies Order Form)
WSLH REFERENCE MANUAL AND FEE
SCHEDULE AVAILABLE ON OUR WEBSITE:
http://www.slh.wisc.edu/publications/

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