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NC Department of Health and Human Services
State Laboratory of Public Health
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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.

Specimen Submittal Forms

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

Form Number Name; Posted Date

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
  • 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; 09/18/2020
DHHS-3445 Special Serology Form; 03/12/19
DHHS-3446 Syphilis Serology Form; 08/15/17
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; 08/28/20
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

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

 


 

NCDHHS

Updated: September 18, 2020