Test Request Forms

The Bureau of Laboratories' test requisitions are updated frequently. Please download and use the most recent version.

Download a test requisition form from the selection below: 

For best printing of forms, use the print button on the PDF 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 - updated 4/26/2016
  • CD4/CD8 & HIV-1 Viral Load Testing DCH-0583 (form change) - updated 2/26/2016
  • 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 - updated 3/17/2016
  • Emerging Arbovirus Panel DCH-0583 - updated 5/6/2016
  • Environmental Lead Sampling DCH-0558 - updated 9/30/2015
  • HIV-1 Genotyping DCH-0583 (form change) - updated 2/26/2016
  • Microbiology/Virology DCH-0583 - updated 2/26/2016  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 2/12/2016
  • Tick Identification and Test Form (MDARD form) - updated 2/12/2016
  • 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. For more information, please call 517-335-8110 for Newborn Screening and 517-241-5583 for all others.

  • 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 endocervical, urethral, rectal and pharyngeal swabs
  • DCH-0974 - packaging and shipping instructions for N. gonorrhoeae and C. trachomatis testing
  • DCH-0975 - collection of urine specimens 

Rev.  5/6/2016