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NC Department of Health and Human Services
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Forms

Forms that are available without requesting a sample kit are listed below. If you cannot find a form below, and/or a form is referenced on another page but no link is provided, then it is likely a form that is available only with a sample kit. Newsletters and bulletins have moved to laboratory improvement.

**NOTICE** All clinical specimen submittal forms were updated on October 18, 2021 to add Medicaid Insurance ID Number. New forms can be downloaded and utilized immediately but MUST be used for all clinical specimen submissions to NCSLPH no later than Monday, November 15, 2021. Please ensure all old forms are destroyed and are not used after this date.

Specimen Submittal Forms

Instructions for Filling Out Specimen Submission Forms (PDF, 16 KB)

Form Number Name; Posted Date

Important, read first!! The CDC updated the 50.34 DASH form in November 2021 to be an executable file. You will be redirected to the CDC website to download and install the new form. The CDC has also provided a job aid on using the new 50.34. The form must be filled out entirely before exporting a printable PDF. Please call our Customer Service team at 919-733-3937 if you have any questions.

CDC 50.34 DASH Form; 12/01/2021
DHHS-1111
  • HIV and/or HCV Form; 10/18/2021
  • Instructions for HIV/HCV Testing Report Forms; 10/18/2021
DHHS-1188 Rubella Serology; 10/18/2021
DHHS-1245 Parasitology Form; 10/18/2021
DHHS-1247 Mycobacteriology (TB) Form; 10/18/2021
DHHS-1614 Rabies Examination Form; 04/27/15
DHHS-1814 Food Environmental Sample Collection Report Form; 04/01/13
DHHS-1859WB Hemoglobin Electrophoresis -- Whole Blood; 10/18/2021
DHHS-2010 Mycology Form; 10/18/2021
DHHS-2887 Public Water Supply Analysis; 07/01/21
DHHS-3390 Enteric Bacteriology Form; 10/18/2021
DHHS-3431 Virology Form; 10/18/2021
DHHS CVD19 (ETOR) COVID-19 Online Submission Form; 11/01/2021
DHHS-3445 Special Serology Form; 10/18/2021
DHHS-3446 Syphilis Serology Form; 10/18/2021
Blood Lead Analysis Form; 10/18/2021; Prenatal testing available only to local health departments
DHHS-3722 Hepatitis Serology Form; 10/18/2021
DHHS-4011 Chlamydia/Gonorrhea Detection Form; 10/18/2021
DHHS-4121 Special/Atypical Bacteriology Form; 10/18/2021

Client Information Forms

Use this form to sign up as a new specimen submitter:

New Client Information Form (PDF, 162 KB)

For current submitters, use this form to change contact information (Name, EIN, Address, etc):

Client Change of Information Form (PDF, 187 KB)

Patient Request Form to Obtain Completed Laboratory Results

Two forms are required for the NCSLPH to be permitted to release laboratory results to patients. The NCSLPH is not responsible for interpreting laboratory test results.

  1. The HIPAA Authorization Form (PDF, 69 KB) grants the NCSLPH consent to distribute patient results.
  2. The Patient Request for Release of Completed Laboratory Results (PDF, 71 KB) confirms who is receiving the information.

Bioterrorism Forms

Mailroom Supply Requisition Forms

Order Supplies from Mailroom Online

N.C. Drinking Water Lab Certification

Documents

Safety Data Sheets for Media Supplied by NCSLPH

Please click on links to view and print the safety data sheets (SDS) for information on potential hazards contained in media supplied by NCSLPH.

Kit Name Media Name Hazards
Bordatella pertussis Regan Lowe
Viral testing Viral Transport
Ova and parasite detection ATS Para-Set 10% Buffered Formalin Fixative
Enteric culture ATS Enteric Transport Media
MTMII Agar Thayer Martin, Modified Agar