| CMPT08/A/08/2011 Trichomonas vaginalis Antigen Report Form | ||||||
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| Laboratory Name: | Laboratory No: | |||||
| Date Received: | Date Reported: | |||||
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Instructions: 1. Please ensure that the package you received contains 4 samples. If your package does not contain 4 samples, contact CMPT as soon as possible. Each sample consists of a small vial of sample material and a sterile swab. 2. Samples are stable for 10 days from date of shipment. Please process as soon as possible and report the results before the due date. 3. Remove the swab from the envelope and place it in the vial of sample material for 10 seconds to less than 1 minute. DO NOT immerse the swab for more than 1 minute. 4. Proceed according to the Genzyme OSOM® Trichomonas Rapid Test Kit instructions. 5. Indicate below if the Trichomonas vaginalis sample is negative or positive for antigen. Please submit results by e-mail to CMPT (cmpt@interchange.ubc.ca) or by fax (1-866-580-2678 or 604-875-4100). Preliminary results will be posted on the web, www.cmpt.ca and reports will not be accepted after preliminary results have been posted online. |
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| SPECIMEN NO.: | □ negative | □ positive | ANTIGEN Method (please specify): | |||
| SPECIMEN NO.: | □ negative | □ positive | ANTIGEN Method (please specify): | |||
| SPECIMEN NO.: | □ negative | □ positive | ANTIGEN Method (please specify): | |||
| SPECIMEN NO.: | □ negative | □ positive | ANTIGEN Method (please specify): | |||
| Comments: (if applicable) | ||||||
| Name (please print): | Date: | |||||