Form 2a. NTP Lab Request and Result Form
Form 2a. NTP Lab Request and Result Form
Form 2a. NTP Lab Request and Result Form
Date Specimen Collected: Specimen Date of Collection If for Xpert, DST or LPA:
1 Presumptive DS-TB [ ]
Test
Test Requested:
Requested: [ ] DSSM [ ] Xpert MTB/RIF [ ] Culture [ ] DST
If for Xpert, DST or LPA:
[ ] LPA
If for Xpert, DSSM Result: ___________ If for Presumptive
DST, Xpert Result: _____________
Drug-Susceptible TB
Test If for[ DST,
] HIV Result: ______________
Test Requested:
Requested:
Prepared by: ___________________________________________ Position: ____________________________
Presumptive Drug-Resistant TB
Signature over Printed Name
[ ]
Test Requested:
Portion below to be filled-out by Medical Technologist/Microscopist/Xpert Technician
Presumptive Drug-Resistant TB
*Specimen 2 is notDST
applicable for follow-up [ ]
** Muco-purulent, blood-stained, salivary, etc.
A separate result form for TB Culture, and LPA will be issued.