CMPT07/D/05/2012 Clostridium difficile Antigen/Toxin Report Form

Laboratory Name:			Laboratory No:
Specimen No:	Patient No:	Date Received:	Date Reported:

Please indicate below if the C. difficile sample is negative or positive for Common/GDH ANTIGEN (if indeterminate please indicate in the comments sections) Negative Positive not tested ANTIGEN (Common/GDH) Method(s) (please specify): COMMENTS:   Please indicate below if the C. difficile sample is negative or positive for TOXIN or TOXIN GENE (if indeterminate please indicate in the comments sections) Negative Positive not tested TOXIN/TOXIN GENE Method(s) (please specify): INTERPRETIVE COMMENTS: (if applicable)   Signature: Date:

Please note: This Print from Screen report form may be printed and used to submit results to CMPT via faxing completed forms to 604-875-4100. (This form may not print as a single page - depends on your browser). Currently, results may not be submitted via the CMPT web site.