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

PRIMARY CUSTOMER ADDRESS


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

* Primary Address Classification 

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

Pick-Up?
calendar

Map
 


Ship-To Address
If different than primary address, provide shipping information below.

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


Shipping Address Classification 


Bill-To Address
If different than primary address, provide billing information below.


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


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

<- 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.

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

 

<- 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.)



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

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

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

<- Blood mailer(s) only, not collection tube(s).
<- Used by all submitters not covered by HIV grants.
Contains:
(1) Styrofoam box
(1) refrigerant gel pack
(1) large biohazard specimen bag
(1) shipping manifest
<- Yellow tubes for male and female urine specimens.

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
Contains:
(10) 50 mL conical collection tubes 
(10) absorbent paper capable of
        absorbing 10-15 mL of liquid  
(10) small biohazard specimen bags
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


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)


Send form(s) by

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

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

<- Used to mail specimens to the lab.

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.

Urgent Orders & Shipping Information



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

Check below regarding urgent need for testing supplies:

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