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.

Specimen Submittal Forms

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

Form Number	Name; Posted Date
CDC 50.34 DASH Form Important, read first!! If your browser's PDF viewer does not display the CDC DASH form (i.e., you see an error page), try right-clicking on the link and saving the file ("Save Link As" from the menu) to your computer, then opening the file from the location where you just stored it on your machine (e.g., your desktop) using a PDF viewer such as Adobe Reader (deselect the "Optional offers"). Why? The default PDF viewer plug-in for certain browsers, such as Chrome and Firefox, will not open the file.	CDC 50.34 DASH Form; 03/11/2020
CDC 50.34 Instructions/Training	FEMB Specimen Submission Form Training
DHHS-1111 DHHS-1111 Instructions Label Format Specifications (Forms DHHS 1111, 3707)	HIV and/or HCV Form; 08/21/17 Instructions for HIV and/or HCV Testing Forms; 08/21/17
DHHS-1188	Rubella Serology; 08/15/17
DHHS-1245	Parasitology Form; 08/15/17
DHHS-1247	Mycobacteriology (TB) Form; 08/15/17
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; 08/15/17
DHHS-2010	Mycology Form; 08/15/17
DHHS-2887	Public Water Supply Analysis; 04/24/13
DHHS-3390	Enteric Bacteriology Form; 08/15/17
DHHS-3431	Virology Form; 03/02/2020
DHHS CVD19	COVID-19 Submission Form; 03/27/2020
DHHS-3445	Special Serology Form; 03/12/19
DHHS-3446	Syphilis Serology Form; 08/15/17
DHHS-3707 Label Format Specifications (Forms DHHS 1111, 3707)	Blood Lead Analysis Form; 10/19/16; Prenatal testing available only to local health departments
DHHS-3722	Hepatitis Serology Form; 05/30/19
DHHS-4011	Chlamydia/Gonorrhea Detection Form; 10/23/18
DHHS-4121	Special/Atypical Bacteriology Form; 08/14/17

Client Information Forms

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

New Client Information Form (PDF, 74 KB)

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

Client Change of Information Form (PDF, 55 KB)

Patient Request Form to Obtain Completed Laboratory Results

Complete all required information on form and submit proof of identification as requested on page 2 of form. Mail or fax to 919-715-8610. The Laboratory is not responsible for interpreting laboratory test results.

Patient Request for Release of Completed Laboratory Results (PDF, 71 KB)

Bioterrorism Forms

• DHHS 4118: Suspicious Package or Bioterrorism Sample Form (PDF, 166 KB)
• DHHS 5010: BT and Emerging Pathogens Clinical Form (PDF, 124 KB)
• Chain of Custody Form (PDF, 166 KB)

Mailroom Supply Requisition Forms

Order Supplies from Mailroom Online

N.C. Drinking Water Lab Certification

• Certification Rules - North Carolina Drinking Water Certification Rules (2004)
• Certification Application (PDF, 41 KB) - North Carolina Drinking Water Certification Application

Documents

• Packaging and Shipping Instructions for Blood Lead (PDF, 298 KB)
• Packaging and Shipping Instructions for Hemoglobinopathies (PDF, 57 KB)
• Packing Instructions Using Outer Baggie (PDF, 4.6 MB)

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	Amphotericin B Cephalexin hydrate Charcoal Agar (CM0119) Defibrinated Sheep Blood
Viral testing	Viral Transport	Gelatin Tryptose Phosphate Broth
Ova and parasite detection	ATS Para-Set 10% Buffered Formalin Fixative	10% Formalin
Enteric culture	ATS Enteric Transport Media	ETM
MTMII Agar	Thayer Martin, Modified Agar	MTMII