NATIONAL TUBERCULOSIS, LEPROSY AND LUNG DISEASE PROGRAM/NATIONAL TUBERCULOSIS REFERENCE LABORATORY

LABORATORY REQUEST FORM

******ALL FIELDS ARE MANDATORY******

PATIENT INFORMATION

Full Name (3 Names)*: ………………………………………………………………………………………………………….. Age*: ……………………………......... Sex*: Male Female

Mobile No*.: ………………………… Alternative Mobile No*: …………………… National Identification / NEMIS No*: ………………………………

Physical Address*: …………………………………. Ward/Department*: ………………………… IP/OP Number*: ………………………… TB / MDRTB Register No*: …………………………

REQUESTER DETAILS

MFL CODE*: ………………Name of facility*: ……………………………………………………………… County*: ………………………………Sub County*: ………………………………………………

Name of clinician*: …………………………………………Facility/clinician Phone Number*: …………………………………Facility/clinician Email*: ……………………………………………………

Name of SCTLC*: …………………………………………SCTLC Phone number*: ……………………………………SCTLC Email*: ……………………………………………………

CMLC/SCMLC Name*: ………………………………………………………………………… CMLC/SCMLC Email address*: ........................................................................................

RELEVANT CLINICAL INFORMATION (Tick (√) where appropriate)

Type of Patient: HIV Status Type of TB:

DS TB DR TB

New ( ) Positive ( ) PTB ( ) INH Mono Resistant ( )

Failure of Retreatment ( ) Negative ( ) EPTB ( ) RR ( )
Relapse Smear positive: ( ) Declined ( ) TB Adenitis ( ) MDR ( )
Relapse Smear Negative: ( ) Not done ( ) Skeletal TB ( ) Poly drug resistant ( )
Failure of First Line ( ) TB Meningitis ( ) specify:……………
Treatment after loss to follow up ( ) Date tested: …………… Other (Specify) ……………………………………. Pre XDR ( )
DR TB follow up ( ) XDR ( )

Reasons for Examination (Tick (√) where appropriate)

Drug sensitive TB: New ( ) Follow up 2 Months ( ) 3 months ( ) 5 months ( ) 6 months ( )

Drug resistant TB: Baseline ( ) Follow up ( ) Specify Month of follow up: ………………………………………..

SAMPLE DETAILS (Tick (√) where appropriate)

Sample type Test requested:

Sputum ( ) Others: …………………………. Smear Microscopy ( ) Other Tests

CSF ( ) GeneXpert ( ) TB LAM ( )
Gastric aspirate ( ) First Line LPA ( ) Sequencing ( )
Pleural fluid ( ) Second Line LPA ( ) BD MAX ( )
Stool ( ) Culture ( ) TRUENAT ( )
Urine ( ) DST First Line ( )
Ascitic fluid ( ) DST Second Line ( ) Interferon Gamma Release Assay (IGRA):
FNA ( ) a) Quantiferon ( )
Lymph node biopsy ( ) b) T- spot ( )
Nasopharyngeal aspirate ( )

Date of sample collection: …………...... Time: ………………..................... Date sample received at testing lab: ………………….......... Time: ………….......................

Low Risk for DR TB High Risk for DR TB

All Presumptive TB cases who are not in the high risk group including: ( ) Previously treated TB patients: treatment failures
( ) People Living with HIV with TB symptoms ( ) Drug Resistant TB patient contacts
( ) Children <15 years with TB symptoms ( ) TB patients with a positive smear result at month 2, 3 or 5 of TB
( ) All Presumptive TB cases treatment
( ) Patients who develop TB symptoms while on IPT or has had
previous IPT exposure
( ) Healthcare workers with TB symptoms
( ) Prisoners with TB symptoms
( ) Refugees with symptoms of TB

LAB REPORT (LAB USE ONLY)

Date: …………................................ Time Sample Tested: …………............................. Method used: ZN FM Xpert

Lab serial no Specimen type Visual Appearance Results

Neg Actual no. + ++ +++ Xpert TB LAM Others: Date & Time
results** ……………….... dispatched

Pos | Neg

**select one of the following

TS: MTB detected Rif resistance not detected N: MTB not detected

RR: MTB detected & Rif resistance detected I: Invalid/No results/Error

TI : MTB detected Rif resistance indeterminate Tr: MTB detected Trace

Examined by (Name and Signature) ........................................... Laboratory Name ..................................................... Date.................../.................../...............

...
Reviewed by (Name and Signature) ............................................ Laboratory Name ......................................................... Date................/....................../...............

MOH/F/DNTLDP/05 September 2020 Effective date: 01/10/2020