Quantiferon-TB Gold
| PATIENT INFO |
| Patient Name: |
| Medical Record #: |
| BD: / / Sex: F M |
| PHYSICIAN INFO |
| Physician Name : |
| Address: |
| Ph: ( ) - Fax: ( ) - |
| Additional Report to: |
| Ph: ( ) - Fax: ( ) - |
| TESTS REQUESTED | |
| Test Name: | ICD9 Code: (required) |
| 1. Quantiferon-TB Gold | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
QUTBG
Test Workstation :
SUMMA
Specimen Type:
Whole Blood
Tube Type:
Please contact Sendouts 330-543-8570 or 330-543-8571 for collection kit; special tubes required for this assay:
Grey (Quantiferon NIL) top tube,
Green (Quantiferon TB1) top tube,
Yellow (Quantiferon TB2) top tube,
Purple (Quantiferon Mitogen) top tube.
Collection Volume:
4- 1 mL tubes
Cause for Rejection:
If specimens are not collected and processed according to the collection procedure, refrigerated, frozen, or QNS specimen.
Storage:
Ambient
Availability:
Sent to Reference Lab
Methodology:
Lymphocyte Stimulation with ELISA
Special Instructions:
Specimen Collection Procedure: (Call lab for special tubes)
1. Draw four tubes in the following order: Grey,then Green,then Yellow,then Purple top tube. Important: Gray tube first.
2. The tubes are vacuumed to only accept 1 mL. Tubes fill slowly so
keep tube on the needle for 23 seconds after tube appears to have
completed filling (up to the black line).
3. When tubes are filled shake VIGOROUSLY AND MAKE SURE THE INSIDE OF
THE TUBE IS COATED WITH BLOOD for 1012 seconds. The shaking is
extremely important as there are reagents in the tube.
4. Send immediately to the Centralized Core Lab (CCL). Tubes need processed no later than 16 hours after collection. CCL staff: send to SUMMA with a routine day shift courier during the week and call a STAT courier on weekends, holidays, and PM/MN shifts.
5. It is preferred that the specimen is drawn the morning of testing and received in Akron Childrens lab by 10:00 AM.
Lab/Phone:
330-543-8418
TAT:
48 hours
Additional Info:
Reference range available on patient report.
CPT Code:
86480
