H1 Healthcare Pathogens Characterisation and Resistance (multiple isolates) Bacteriology Reference Department Phone: +44 (0)20 8327 7887 (AMRHAI) [email protected] 61 Colindale Avenue, London NW9 5HT www.gov.uk/phe PHE Microbiology request form Please write clearly in dark ink PHE Colindale Bacteriology DX 6530002 Colindale NW SENDER’S INFORMATION Report to be sent FAO Sender’s name and address Contact Phone Ext Purchase order number Project code PHE outbreak/investigation Postcode ILog number INVESTIGATION DETAILS Investigation required Typing Do you suspect that any of the isolates you are referring could Yes No be Hazard Group 3 ? (please specify) Please provide preliminary ID and laboratory results PVL toxin gene detection only (S. aureus only) Presumptive Identification Extended toxin gene detection (S. aureus only) Genomovar determination (B. cepacia – complex only) MIC evaluation (Specify reason below) ESBL detection mecA/C PCR Carbapenem resistance mupA/B PCR Acquired AmpC Linezolid resistance S. aureus MRSA S. aureus MSSA Coag Neg Staph Acinetobacter B. cepacia complex Enterobacter Enterococcus E. coli Klebsiella P. aeruginosa Serratia S. maltophilia Other (please specify) Reasons for referral Medico-legal case Surveillance Unusual resistance New investigation Inter-hospital transfer Continuing investigation* Therapeutic guidance Additional information (please provide gram stain if unknown organism) * Please provide PHE investigation code and/or HPA reference numbers for previous requests Date sent to PHE PATIENT/SOURCE INFORMATION Patient NHS number Forename Patient Surname Forename Clinicial information Sampling reason Isolation site Acquired in Date/time of collection Staff Ward name Y BAC PNE Patient Staff Isolation site Acquired in Ward name DOB BAC PNE Sampling reason Isolation site Acquired in Date/time of collection Patient NHS number Staff Forename Ward name DOB Sex BAC PNE FATA = Fatal SSS = Scalded Skin All requests are subject to PHE standard terms and conditions FEV = Pyrexia/Fever TSS = Toxic Shock FEV TSS Clinical Screening Hospital Community FATA SSS FEV TSS Clinical Screening Hospital Community END SKI Your reference Sampling reason Isolation site Acquired in Date/time of collection FATA SSS Symptoms* Ward type Surname Community END SKI Your reference Sex Hospital Symptoms* Ward type Forename Screening END SKI Sampling reason Date/time of collection Clinical Symptoms* Your reference Sex Surname END = Endocarditis SKI = Skin Infection Y Sample information Ward type NHS number *Symptoms BAC = Bacteraemia PNE = Pneumonia M Your reference Sex DOB REFERENCE LABORATORY USE ONLY Staff Ward name NHS number REFERENCE LABORATORY USE ONLY M Ward type Surname DOB REFERENCE LABORATORY USE ONLY D Priority status Number of isolates submitted REFERENCE LABORATORY USE ONLY D FATA SSS FEV TSS Clinical Screening Hospital Community Symptoms* BAC PNE END SKI FATA SSS FEV TSS Page 1 Continuation page available Version effective from April - 2014 BRDW0139.01
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