Use this form for COVID-19 specimens (revised January 2021)
Infectious Diseases Requisition form DOH-4463 (revised January 2021)
- Please fill in the IDR electronically via fillable PDF or clearly print information on the
- For Mycobacteriology test requests, include only one specimen per form.
- For all other test requests, use one form per patient. Note: it is acceptable to submit
multiple sample types from one individual, as long as they are all from the SAME
collection date and included on one form.
- *Required Information: Items marked with an asterisk * indicate required information
- Shipping specimens using Courier services is preferred for most infectious disease
testing at Wadsworth. Please use the indicated courier address.
- Courier services MUST be used for shipments of Category A organisms (i.e. TB),
expedited test requests or those being directed to the Biodefense and Viral Diseases
Laboratories. Please use the indicated courier address.
- Please note, the specified Courier Address listed for shipping specimens to the Rabies
Virus Laboratory. Rabies samples not addressed to the Slingerlands Courier address
will result in a testing delay.
- Refer to the Wadsworth Center Test Catalog on the Health Commerce System (HCS) for
test-specific shipping information or call with questions (518-474-4177).
Patient Demographics and Requesting Provider
A minimum of two of the following patient identifiers are required:
- patient first and last name
- OR the submitter’s patient reference number
- AND date of birth (DOB).
Name: The name on the IDR must match labels on all specimen containers.
DOB: Date of birth in MM/DD/YYYY format. (required)
Patient Address: patient’s permanent street address. Facility of Residence should be included ONLY if the patient resides at a facility other than an individual home or apartment, i.e. a nursing home, at the time of illness. If applicable, please include the name and type of facility.
County of Residence: This is the county of the patient’s permanent street address. This ensures relevant required information is relayed to the appropriate jurisdiction for follow up, when needed. (required)
Patient Reference Number: a specific number for the patient i.e. a medical record number (MRN). This is NOT a social security number.
Outbreak number: Include this if the patient is part of an outbreak and if a specific number has been assigned by state or local officials.
CDESS (Communicable Disease Electronic Surveillance System) Case Number: Include if one has been assigned by state or local officials.
Requesting Healthcare Provider: please include the name and contact number for the healthcare provider requesting testing at the Wadsworth Center. This information may be needed by Wadsworth labs for questions regarding test request(s) and/or to relay critical test results.
Note: this does not have to be the patient’s primary care physician.
NPI (National Provider Identifier): This is a unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services (CMS). Please include it if available.
Name and Address: include the NAME and address of the facility/laboratory shipping the specimen(s) to Wadsworth for testing. This is the facility to which Wadsworth laboratory reports will be sent. Note: if neither a submitting address nor a PFI is included on the IDR, a laboratory report CANNOT be sent. (required)
PFI: Permanent Facility Identifier. This is an ID number for permitted clinical laboratories. Please include, if applicable.
NPI: see above.
Contact Person: name and telephone number of the most appropriate individual to answer questions about the specimens and/or shipment details. (required)
Collection Date: enter the date of specimen collection in MM/DD/YYYY format. (required)
Time Collected (if applicable): enter the time of specimen collection, if applicable and available.
Date of Symptom Onset: enter the date on which symptoms began in MM/DD/YYYY format. This is particularly important for the performance of some tests; refer to the Test Catalog available on the Health Commerce System (HCS).
Autopsy: select if the specimen(s) were collected post mortem.
Source: Type of material being submitted for testing or from which an isolate being submitted was generated. Use multiple lines if submitting more than one specimen. Examples include, but are not limited to: blood, serum, stool, sputum or bronchial aspirate. (required)
Submitted On/In: If applicable, include any media, preservative or cell line in which the submitted specimen has been collected or in which it is being transported.
Specimen Type: Isolate refers to a subpopulation, generated from any primary clinical material. Isolate examples include bacterial cultures or cultured viral isolates. Primary refers to original clinical material, directly collected from the patient. Please check one for each specimen submitted.
Submitter’s Specimen Identifier: identifying number, assigned by the laboratory submitting the specimen to Wadsworth.
Note: each specimen submitted should have an individual Specimen Identifier, though they are not required for testing.
Laboratory Examination Requested
Confirmation: select if testing is being requested in order to confirm results. This includes specimens sent as required by the NYS Reportable Diseases Guidelines. Please also include specific details from the Program section below.
Identification/Detection: select if testing is being requested for the identification or detection of an unknown or suspected microorganism(s). Please also include specific requests from the Program section below.
Submitter Lab Findings: list all appropriate laboratory examination findings, including the method used to obtain results.
Suspect Organism/Agent (either side): please select the Wadsworth program(s) in which testing is being requested. Check the box to the left of the specific program AND list any suspected organism(s)/agent(s) on the line to the right.
Note: please do not check more than one laboratory unless testing is being requested in more than one program. Please refer to the Wadsworth test catalog on the HCS for details on tests offered.
Program Specific Instructions:
- Bacterial: None
- Fungal: None
- Mycobacterial: Please complete a separate IDR form for each specimen submitted for mycobacterial testing.
- Parasitic: Under Clinical History (see below for instructions) please include travel history when known or indicate unknown. Please note drug susceptibility is currently performed if requested and only on samples containing P. falciparum. Specimens with a very low parasitemia may not be suitable for susceptibility testing.
- Serology: None
- Viral: Please be sure to complete the Clinical History section (see below for instructions). Influenza antiviral susceptibility testing is available on a case-by-case basis. Please provide details, including specific antiviral, duration and an explanation of why resistance is suspected. Out-of-season requests for arbovirus testing require relevant explanations to avoid canceled or delayed testing. Provide current and alternate contact information to receive critical test results.
- Other: Referral testing, please list organism and include any additional paperwork required (i.e. current CDC Dash form).
Clinical History (this section is mostly used for suspected viral illnesses)
Relevant exposures: Please be sure to select the relevant exposure AND provide details on the description line available, if applicable. Note: additional details and prior authorization may be required for some testing. Please refer to the Wadsworth test catalog on the HCS for a current list of testing, requirements and details. If unsure, please phone the laboratory, (518) 474-4177. Travel details, including location and dates are requested for: malaria, arboviruses (i.e. dengue virus, chikungunya virus, Zika virus), MERS coronavirus and novel influenza testing.
Hospitalized: If the patient is hospitalized, please list the hospital. This information is helpful for contacting relevant medical personnel regarding patient testing.
Diagnosis: please provide any information about diagnosis that may be helpful in test selection and/or interpretation.
Relevant Treatment: please provide any relevant treatment details, including dates.
Relevant Immunization: please provide any relevant immunization details, including dates. This MAY be important for some test interpretations.
Symptoms: please indicate ALL applicable symptoms. Utilize the line provided next to “Other symptoms” to list any symptoms not specifically listed.