CMPT05/G/10/2009: Urine Report Form
Laboratory Name:

 Laboratory No:
Specimen No: Source/Site:
Date Specimen Received: Date Specimen 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.
This laboratory only receives urine samples transported on dip slides.
Isolation Precaution: Infection control, ward or designate would normally be notified.
A notification to Public Health would normally be submitted.
Other comments (please specify):  
Please Note: 
  1. For ALL urine samples, provide the EXACT wording your laboratory would include in a final clinical report for this urine sample. This may include, free text comment, microbial identification, or both or none. 
  2. If an organism identification is applicable, please note the method below.
  3. If susceptibilities are to be reported, record them using the CMPT Susceptibility Testing
    Results Form (CMPT02/E/10/2009). Only report susceptibility results that would be reported if this were a true clinical sample.
Urine Colony Count (CFU/L):  
Final clinical report (Please use EXACT wording):  

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.)