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 02/01/2019
  • CD4/CD8 & HIV-1 Viral Load Testing, DCH-0583 (form change) - updated 05/17/2018
  • 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 Test Request Form - updated 12/09/2020    NOTE: If you are unable to view this form, right click on the "CDC Test Request Form" link and select "Save link as..." (wording may vary between browsers) to download/save the file as an Adobe document.
  • CDC Lyme Disease Case Report Form, CDC 52.60
  • Chlamydia trachomatis/Neisseria gonorrhoeae/Trichomonas vaginalis (non-culture), DCH-1248 - updated 09/08/2020
  • COVID-19 (SARS-CoV-2) Antibody Detection, MDHHS-5929 -  added 03/11/2021
  • COVID-19 (SARS-CoV-2) Molecular Detection, MDHHS-5891 -  updated 09/24/2020
  • COVID-19 (SARS-CoV-2) Sequencing Requisition, MDHHS-5905updated 08/10/2021
  • Emerging Arbovirus Panel, DCH-0583 - updated 5/6/2016
  • Environmental Lead Sampling, DCH-0558 - updated 10/02/2017
  • HIV-1 Genotyping, DCH-0583 (form change) - updated 05/17/2018
  • Influenza SARS-CoV-2 Multiplex Assay, MDHHS-5895 -  updated 12/23/2020
  • Microbiology/Virology, DCH-0583 - updated 12/28/2018  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 05/12/2020
  • Rabies Testing,  DCH-1053- updated 02/25/2019
  • Sentinel Physician, DCH-1583Sent - updated 12/28/2018
  • Tick Identification and Test Instructions - updated 02/08/2017
  • Vaccinia/Variola/Pox Virus, DCH-1396 - updated 2/2/2012
 

The following test requisitions 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 Acting Trace Metals laboratory manager, phone 517-335-8357, or E-mail at FisherK@michigan.gov.
  • Blood Spot; HIV - DCH-0689 (Instructions) To order, please contact the MDHHS-BOL Warehouse by email at mdhhs-warehouse-bol@michigan.gov.
  • PCB & Pesticide Test DCH-0571 To order, please contact the Analytical Chemistry laboratory manager, phone 517-335-9490, or E-mail at GeigerM@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 517-284-9370
  • 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.  08/10/2021