Public Health Testing Supply Order Form

This order form is for epidemiologists, veterinarians, animal control agencies,
public health agencies or healthcare facilities.

Local public health agencies ordering supplies in response to an outbreak -
should first contact CDPHE Disease Control and Environmental Epidemiology at:
303-692-2700

For specimen collection instructions (stool, vomit or food) visit this online instruction guide.
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If you are a member of the general public, and would like to have testing for
any of the conditions listed below, please visit your healthcare practitioner.
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For bacterial water testing, visit the online Water Testing Supplies Order Form.
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Supplies are free to customers who are submitting specimens/samples to the
Laboratory Services Division for testing.
They should not be ordered for your institution's in-house use.

The Laboratory Services Division reserves the right to limit quantities based on supply availability.

Veterinarians or animal control agencies ordering Test Request Form #272 for animal testing:

1. Enter your contact information, including fax number & check New or Current Customer (below), then

2. Scroll to the bottom of this page and check Req#272 under Test Request Forms.

Customer Information

* Customer Status

New Customer

Current Customer - Do not recall customer number

Current Customer - Customer number(s) provided below

Customer ID Number

PRIMARY CUSTOMER ADDRESS

* First Name

* Last Name

* Company Name (if applicable):

*

PRIMARY Street Address

Dept/Suite/Floor

* City

* State

* Zip Code

* Phone Number

Fax Number

Email

Confirm Email and receive order receipt

<- If left blank, no order receipt will be sent.

* Primary Address Classification

Business address

Business operating from a residential address

Residential address

(Allow 2 days for processing your order before picking it up)

Pick-Up?

Will pick up supplies/kits from State Lab

Earliest Date of Pick-Up

Map

Ship-To Address

Same as primary customer address above

If different than primary address, provide shipping information below.

First Name

Last Name

Company Name: (if applicable)

Shipments are sent by FedEx and cannot be sent to P.O. Boxes

SHIPPING Street Address

Dept/Suite/Floor

City

State

Zip Code

Shipping Address Classification

Business address

Business operating from a residential address

Residential address

Bill-To Address

Same as primary customer address above

If different than primary address, provide billing information below.

First Name

Last Name

Company Name: (if applicable)

BILLING Street Address

Address Line 2

City

State

Zip Code

Phone Number

Results-To Address

Same as primary customer address above

If different than primary address, provide address information for sending test results in the spaces below.

First Name

Last Name

Company Name: (if applicable)

RESULTS Street Address

Address Line 2

City

State

Zip Code

Phone Number

Supply List

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The Laboratory Services Division reserves the right to limit supply shipments based on
customer usage and supply stock.
Please limit ordering to several months of supplies only and do not order a year's stock.

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Enteric Testing Supplies

Questions about testing? Contact the lab at: 303-692-3480

Questions about your supply shipment? See contact information at the end of this form.

Click on the question mark under the kit name for complete list of kit items.

Outbreak Investigation Testing Supplies

Enteric Culture and Bulk Stool Kits are most frequently ordered for outbreak investigations.
Occasionally Parasitology Kits may be required.
For questions contact CDPHE Epidemiology at: 303-692-2700.
Refer to collection instructions guide.

Quantity

Enteric culture kit (12 pack - Amies transport swabs)

<- Rectal/fecal specimen sites.
    Send to lab within 72 hours
    of collection. (Contains bacterial
    growth nutrients.)

Bulk stool kit (6 pack - straightside jars)

<- For foodborne bacterial or norovirus testing
on stool.
IMPORTANT NOTES:
*Bacterial testing on stool collected using this
kit requires that testing begin within 24 hours of
collection (Container does not contain bacterial
growth nutrients.)
RUSH to lab when using kit for bacterial testing.
**Norovirus testing on stool using this kit does
NOT require expedited shipment.

Ova and Parasites (O&P) kits

Whirl-Pak sterile sample bags

<- Used for collection of food samples for bacterial testing.
    NOTE: DO NOT use this order form to order annual supply
    of these collection bags.
    This order form is for small quantities only.

Routine Enteric Testing Supplies

Supplies for testing unrelated to outbreak investigations.

Quantity

Amies transport swabs

<- Used to send bacterial isolates,
including EIP isolates (except C. difficile),
or rectal/fecal for enteric bacterial
testing within 72 hours of collection.

Stuart’s collection/transport swabs (50) pack

EIP Customers ONLY

Straightside jar

<- Used for foodborne bacterial & norovirus testing of stool.
    NOTE: Bacterial testing requires specimen shipment within 24 hours
    of collection.
    Norovirus specimens should be stored at 4oC until they can be shipped
    (This collection container does not have bacterial growth enhancement media.)

Stool mailer (6x4x4 box w/clear plastic screw cap canister)
for Campy confirmation. [Ship to lab on cold packs]

Sterile spoons

Influenza Testing Supplies

Supplies for influenza testing are provided to designated facilities upon request only (restrictions apply.)

Influenza specimen collection kit (includes 1 test requisition form for copying)

Pertussis Testing Supplies

Questions about testing? Contact the lab at: 303-692-3286

Questions about your supply shipment? See contact information at the end of this form.

Click on the question mark under the kit name for list of included items.

Quantity

Pertussis Kit

Dacron swabs

5 ml saline tubes

Refugee Clinic Testing Supplies

Quantity

Parasitology Stool Kit (12 Ova and Parasite paired vials)

<- Preserves and
transports stool
specimens for
intestinal parasite
examination.

Large Screw-Cap Cardboard Tube (2.5 diameter for Ova and Parasite vials)

Blood Tube mailer (6x4x4 box w/clear plastic screw cap canister)

Note: Blood mailer(s)
are transportation
containers only, not
blood collection
tube(s).

Sexually Transmitted Disease Testing Supplies

Questions about testing? Contact the lab at: 303-692-3485 (Syphilis/HIV) or 303-692-3695 (CT/GC)

Questions about your supply shipment? See contact information at the end of this form.

Click on the question mark under the kit name for list of included items.

Quantity

HIV or Syphilis blood tube mailers (6x4x4 box w/clear plastic screw cap canister)

Note: Blood mailer(s) are transportation containers only, not blood collection tube(s).

HIV case (42 pack)

<- Blood mailer(s) only, not collection tube(s).

HIV collection ID labels

<- Used by all submitters not covered by HIV grants.

Aptima unisex (endocervical/male urethral/rectal/pharyngeal) PURPLE swab pack (50 count)

Aptima urine pack (50 count)

<- Yellow tubes for male and female urine specimens.

Aptima vaginal swab pack (50 count)

Regular cup (Urine, CT/GC, yellow top)

9 x 12 Manila envelope (CT/GC)

Tuberculosis Testing Supplies

Questions about testing? Contact the lab at: 303-692-3480

Questions about your supply shipment? See contact information at the end of this form.

Quantity

TB specimen collection supplies

Contains:
(10) 50 mL conical collection tubes
(10) absorbent paper capable of

absorbing 10-15 mL of liquid
(10) small biohazard specimen bags

TB mailers

Contains:

(1) Styrofoam box
(1) refrigerant gel pack
(1) large biohazard specimen bag
(1) shipping manifest

West Nile Virus Testing Supplies

Questions about testing? Contact the lab at: 303-692-3286

Questions about your supply shipment? See contact information at the end of this form.

Click on the question mark under the kit name for list of included items.

Quantity

2 ml Screw-cap Tube (Bird)

Bird WNV Kit (10 pack)

2 ml Tube with Ceramic Beads (Mosquito)

Mosquito WNV Kit (20 pack)

Test Request Forms

Check the relevant box(es) below to have your agency's test request form
e-mailed or faxed to you for easy duplication at your facility.

NOTICE: NEW TEST REQUISITION "270-71".
This test requisition is for all human testing
and includes tests for the IPP program.

Send Test Request Form(s)

Req Form #270/71 - *NEW* for all general human testing and Infertility Prevention Program IPP CT/GC testing

Req Form #272 (bird/animal) - only 25 sent at one time and cannot be E-mailed. DO NOT COPY THESE FORMS. (Collection orders are unique and used to track specimens.)

Req Form #273 (insect/mosquito)

Send form(s) by

Email

Fax

You must provide a valid email and fax number
in your contact information above

IMPORTANT NOTE - Requisition #272:
used for bird/animal testing for West Nile Virus, St. Louis Encephalitis, Western Equine Encephalitis, Rabies, Plague or Tularemia. This form contains a auto-generated number and can only be FAXED.

Miscellaneous Supplies

Quantity

Biohazard bags

Large Biohazard bags - used for bulk stool submissions

Biohazard labels

Bottle mailers (Parasitology)

Double mailers

<- Two nesting screw-cap cardboard mailing tubes,
for blood, TB specimens & Amies swabs

Green mailing labels

<- Used to mail specimens to the lab.

Refrigerant packs

Use the space below to request supplies for testing not listed above.
If testing is unavailable, you will be contacted by the Laboratory Services Division.

Comments

Urgent Orders & Shipping Information

Request a FedEx Tracking Number by checking below
(Valid E-mail address is required)

E-MAIL a FEDEX TRACKING NUMBER

Check below regarding urgent need for testing supplies:

URGENT - supplies needed for an outbreak investigation

N/A - supplies are for routine testing

Please note that orders are generally filled within 1-2 business days from receipt of your order and will arrive 5-10 business days later.

Plan to order routine testing supplies prior to low inventories.

If you have not received your order in a timely manner,
contact the lab at 303-692-3294 or cdphe.lab@state.co.us

Click the submit button below to complete your order.

If you do not click the submit button, your order will not be received or fulfilled.

* Indicates Response Required