NATIONAL REFERENCE LABORATORY for HIV/AIDS, Hepatitis B/C & Other STIs CHECK ONE:

San Lazaro Hospital-STD AIDS Cooperative Central Laboratory HIV Antibody Hepatitis C Antibody
Quiricada St., Sta. Cruz, Manila Tel Nos: (632)3109528 to 29, Fax No: (632)711-4117 HIV Nucleic Acid Test HCV Nucleic Acid Test
Email: [email protected] Website: www.nrlslhsaccl.com.ph SYPHILIS HBsAg Neutralization Assay Test
CONFIRMATORY REQUEST FORM
For NRL-SACCL USE ONLY
Patient Name Age: Sex: M F barcode sticker
PATIENT DATA

(Please use comma after surname) Surname First Name M.I.

Date & Time/ Form Received By:

Birthdate (mm/dd/yyyy) : Nationality: Civil Status: Occupation:

Date & Time/ Sample Extracted By:
No Yes (please indicate country visited) _______________________
History of travel abroad within the past 12 months Blood type / Rh:
OR/AMOUNT PAID:
Check specimen type: (check) serum plasma blood unit Date blood collected Date / / Time :
Sample storage condition prior to PATIENT ID:
transport: 4°C (refrigerator) -20°C (freezer) room temperature Date blood transported: Date / / Time :
Remarks:
Unique Identifier Code First 2 letters of Mother's Name First 2 letters of Father's Name Patient's Birth Order Patient's Month of Birth Patient's Year of Birth
(UIC) for HIV referral only
_____ _____ _____ _____ 1st 2nd Others _______

(Any test format) Test- I (Any test format) Test - II INSTRUCTIONS:

1. Completely fill out NRL-SLH/SACCL Confirmatory Request Form. Disregard Test-II if
Complete commercial name of assay: Complete commercial name of assay: only one test format (brand) was used.
2. Serum/plasma samples should be transferred to a 2 ml cryovial prior to transport.
Manufacturer: Manufacturer: Specimens must be PROPERLY labeled (ie. name & date of birth).
TEST RESULTS

- Minimum of 1.5ml sample is required.

Assay Lot #: Assay Lot #: - In case of delay, serum/plasma samples may be stored at 4°C for 7 days (- 20°C for > 7
days).
Model of equipment (reader) used: Model of equipment (reader) used: - If stored at 4°C, ship with ice pack/cold dog.If stored at -20°C or lower, ship with dry ice.
3. Submit this form and sample to NRL-SLH/SACCL or by courier to this address:
RAPID TEST: IMMUNOASSAY RAPID TEST: IMMUNOASSAY
Receiving Section – NRL-SLH/SACCL Annex, Bldg 17, San Lazaro Hospital Compound
Test run (Reactive, Test run (Reactive, Quiricada St., Sta. Cruz, Manila
date/s Nonreactive or Absorbance or date/s Nonreactive or Absorbance or *For HIV referrals, submit the Personal Information Sheet DOH-EB Form A together with
Inconclusive) Cut-off value Inconclusive) Cut-off value
S/CO: S/CO: this Confirmatory Request Form.
Run Run *ONLY HIV confirmatory testing is FREE and results will be available after 10 (working)
1 1 days for samples that meet NRL's Specimen Acceptance Criteria.
*For children below 18 months old, submit NRL's Confirmatory Request Form, EB - Form
Run Run A, EB - A-MC Form and Mother's HIV Confirmatory Result.
2 2 *For further information on referral requirements visit our website or call NRL-SLH/SACCL.

Referring laboratory: Medical Technologist: (Print Name) Signature:

LAB DATA

Address: HIV Proficiency #: (For HIV Referrals) Mobile #

Tel/Mobile No. Fax: e-mail: Pathologist / Laboratory Chief: (Print Name) Signature:

LAB-F-307, Effectively Date:February 2, 2017 Issue 2, Rev. 0

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