Division of Laboratories


Instructions For Use

This form has been created for use with the Adobe Acrobat Reader 5.1 or newer software. If you currently are not using Adobe Acrobat, it is available for download free at http://www.adobe.com/products/acrobat/readstep2.html

This form has been designed for data to be typed electronically. This is the preferred method. If filling out the form by hand, print legibly and in the spaces provided. This will eliminate scanning errors of your sample information, which could delay the reporting of your results. USE CAPS ONLY.

When electronically filling in fields that contain dashes or backslashes, click your mouse pointer on the dash or backslash to select the field and enter the information. Selecting the field itself will not allow you to enter the information, select the dash or backslash.

Each sample must be clearly labeled with the complete patient name and birthdate. Use only one form per each sample. Incorrectly labeled sample tubes may not be tested.

Clear buttons have been placed throughout the form. Use these buttons to clear these areas. This will assist you if you need to fill out multiple forms.

At the bottom of the page you will find buttons to clear or print the form. The print button will print current information on the form. The clear button will reset the form for re-use.

idph online home
about the department

Illinois Department of Public Health
535 West Jefferson Street
Springfield, Illinois 62761
Phone 217-782-4977
Fax 217-782-3987
TTY 800-547-0466
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