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. Ordering instructions are listed for each requisition. 

  • Trace Metals (other than lead) DCH-0976 To order, please contact the Trace Metals laboratory manager, phone 517-335-8244, or E-mail at knottnerusm@michigan.gov.
  • Blood Spot; HIV - DCH-0689 (Instructions) 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.

There is a fee associated with some testing. The following test requisitions must be ordered from Accounting.

  • Medical/Nursing Student/Healthcare Worker Immune Status Antibody Testing - DCH-0459 To order, please call 517-284-9372
  • Newborn Screening - DCH-1153 and DCH-1154 To order, please call 517-335-8110
 

The following (pre-paid) test requisitions are distributed by the Sexually Transmitted Diseases Section. Please call 517-241-0870.

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

Rev.  07/27/2016