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Test Request Forms

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. Please note that most forms are two pages.  It is essential to print and submit the entire form.

  • Blood Lead Test Request DCH-0696 (Two options: Print form, then manually fill in or Type on form, then print)(Instructions for completing form DCH-0696 ) - updated 7/11/2014 
  • CD4/CD8 & HIV-1 Viral Load Testing DCH-0583 (form change) - updated 05/02/2012 
  • CDC Submission Form (NOTE: Submitters must use these forms; Forms and specimens must be sent to the MDCH Bureau of Laboratories for forwarding to CDC; Do NOT change any of the MDCH information on these forms as that will result in a delay in result report delivery.) 
  • CDC Lyme Disease Case Report Form, CDC 52.60 
  • Chlamydia trachomatis/Neisseria gonorrhoeae/Trichomonas vaginalis (non-culture), DCH-1248 (Two options: Print form, then manually fill in or Type on form, then print)- updated 7/11/2014
  • Environmental Lead Sampling DCH-0558 (Two optons: Print form, then manually fill in or Type on form, then print) - updated 7/11/2014 
  • HIV-1 Genotyping DCH-0583 (form change) - updated 12/10/2012 
  • Microbiology/Virology DCH-0583 - updated 02/05/2013  NOTE: This is a 2 page form.  Both pages must be printed, completed and submitted to avoid testing delays.   
  • Multiple Patient/Sample - Same Test DCH-1052 - updated 2/2/2012
  • PCB & Pesticide Test Request DCH-0571 - updated 9/15/2011 
  • Rabies Testing  DCH-1053- updated 8/13/2010  
  • Sentinel Physician DCH-1583Sent - updated 9/11/2009
  • Tick Identification and Test Form (MDARD form) - updated 09/28/2012 
  • Trace Metals Test Requisition DCH-0976 - updated 07/21/2014 
  • Vaccinia/Variola/Pox Virus DCH-1396 - updated 2/2/2012

The following test requisition cannot be downloaded from this site. To order, please contact Mark Warstler at the MDCH Lab Support Unit by Fax 517-335- 9039, phone 517-335-9040, or E-mail at WarstlerMI@michigan.gov.

  • Dried Blood Spot; HIV - DCH-0689 (Instructions) - updated 6/29/2012

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
  • 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).

  • N. gonorrhoeae and C. trachomatis - Combination - DCH-1167C
  • C. trachomatis only - DCH-1167

The following instructions provide guidance for collection of clinical specimens for N. gonorrhoeae and C. trachomatis testing

  • DCH-0972 - collection of vaginal swabs
  • DCH-0973 - collection of rectal and pharyngeal swabs
  • DCH-0974- collection of urethral and cervical swabs
  • DCH-0975 - collection of urine specimens - added 5/5/2011 

Rev.  12/05/2014