CMPT04/G/10/2009:  Clinical Relevancy Results Report Form

Laboratory Name: Laboratory No: Specimen No: Source/Site: Gram Stain report of sample, if applicable: Date Received: Date Reported: Comments  (check all that apply) This laboratory does not process specimens of this type. This sample would normally be submitted to another laboratory for additional investigation. Isolation Precaution: infection control, ward or designate would normally be notified. A notification to Public Health would normally be submitted. For samples (other than urines) which will be assessed by the clinical relevancy scale, please provide the EXACT wording your laboratory would include in a final clinical report for this sample. This may include, free text comment, microbial identification, or both or none. If an organism identification is applicable please note the method below.  If susceptibilities are to be reported, please record them using the CMPT SUSCEPTIBILITY TESTING RESULTS form (CMPT02/E/10/2009).  Only report antimicrobial susceptibility results that would be reported if this were a true clinical sample.       Identification Method(s):   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 - it depends on your browser.)