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 DHHS-0696 - updated 7/24/2015
  • CD4/CD8 & HIV-1 Viral Load Testing DCH-0583 (form change) - updated 08/24/2015
  • CDC Submission Form (NOTE: Submitters must use these forms; Forms and specimens must be sent to the MDHHS Bureau of Laboratories for forwarding to CDC; Do NOT change any of the MDHHS 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 DHHS-0558 - updated 7/24/2015
  • HIV-1 Genotyping DCH-0583 (form change) - updated 08/24/2015
  • Microbiology/Virology DCH-0583 - updated 08/24/2015  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 (Food Outbreak or Non-Human Specimens Only)- updated 01/09/2015
  • PCB & Pesticide Test Request DCH-0571 - updated 9/15/2011
  • Rabies Testing  DCH-1053- updated 8/25/2015
  • Sentinel Physician DCH-1583Sent - updated 9/11/2009
  • Tick Identification and Test Form (MDARD form) - updated 09/28/2012
  • Vaccinia/Variola/Pox Virus DCH-1396 - updated 2/2/2012

The following test requisition cannot be downloaded from this site. To order, please contact the Trace Metals laboratory manager, phone 517-335-8244, or E-mail at knottnerusm@michigan.gov.

  • Trace Metals Test Requisition DCH-0976

The following test requisition cannot be downloaded from this site. To order, please contact Mark Warstler at the MDHHS 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.  08/24/2015