The Bureau of Laboratories is pleased to offer you the option of downloading test requisitions directly to your printer. Some of these forms are fillable prior to printing. All forms are in the process of being converted to fillable forms.
Download a test requisition form from the selection below:
For best printing of forms, use the print button on the Adobe Acrobat software instead of your browsers print button.
- Blood Lead Test Request DCH-0696 (DCH-0696 fillable [This fillable form works best if you download it prior to using
]) -
updated 9/12/2007
- CD4/CD8 & HIV-1 Viral Load Testing DCH-0562- updated 4/3/2009
- CDC Submission Form, CDC 50.34
- CDC Lyme Disease Case Report Form, CDC 52.60
- Environmental Lead Sampling DCH-0558(DCH-0558 fillable [This fillable form works best if you download it prior to using]
) -
updated 7/25/2008
- HIV-1 Genotyping DCH-0562- updated 4/3/2009
- Microbiology/Virology DCH-0583 (DCH-0583 fillable) - updated 9/11/2009
- Multiple Patient/Sample - Same Test DCH-1052
(fillable form)
- Rabies Testing - Lower Peninsula DCH-1053
- Rabies Testing - Upper Peninsula DCH-1438
- Regional Laboratories DCH-0567 (DCH-0567 fillable) - updated 11/21/2008
- Sentinel Physician DCH-1583Sent - updated 9/11/2009
- Trace Metals Test Requisition DCH-0976
- Upper Penninsula Laboratory - Microbiology DCH-0572- updated 6/19/2008
- Vaccinia/Variola/Pox Virus DCH-1396 - updated 6/19/2008
The following test requisitions cannot be downloaded from this site. To order, please contact Craig Fedewa at the MDCH Lab Support Unit by Fax 517-335- 9039, phone 517-335-9040, or E-mail at FedewaC@michigan.gov.
- Dried Blood Spot; HIV - DCH-0698
-
Chlamydia trachomatis/Neisseria gonorrhoeae (non-culture), DCH-1248
The following test requisitions must be ordered by contacting Accounting, as there is a fee associated with the testing. Please call 517-241-5583 for more information.
- Health Care Worker Immune Status Testing- DCH-0460
- Hepatitis C Antibody Screen - FB-202
- Hepatitis C Confirmation - FB-203
- Medical/Nursing Student Antibody Testing - DCH-0459
- Newborn Screening - DCH-1153 and DCH-1154
The following (pre-paid) test requisitions are distributed by the Sexually Transmitted Diseases Section (517-241-0870).
The following test requisition cannot be downloaded from this site. For details regarding ordering, please contact Dr. Bonnie Taffe at 517-335-9490 for more details.
Rev. 9/11/2009