ࡱ> Z]Y $bjbj@/@/ v<"Eg"Eg*L L $PRDL%&(   :::%%%%%%%$'*=%Q:@:::=%  % :  % :% ## y~#%%0%#,B+JbB+#B+#8:: :::::=%=%>:::%::::B+:::::::::L X :  Please perform: Identification l Susceptibility l Typing l Rapid Molecular testing* l Patient s Surname_________________________Forename_____________________________ Hospital Number__________________ Patient s Clinician: _____________________________ Date of Birth_______________M/F Country of Origin/Nationality______________________ Address (mandatory for notification of TB): ______________________________________________________________________________ ______________________________________________________________________________ Referring Laboratory:____________________External Laboratory Number:_________________ Original Specimen Type: Sputum l BAL l BRW l Other (Specify):_________________ Date Specimen Collected______________________ Date Culture Positive_________________ Clinical Details_________________________________________________________________ ______________________________________________________________________________ MDR-TB Contact: Yes/No/Unknown GeneXpert Result (if performed):_________________________RIF resistance detected: Yes/No Susceptibility Result if Known (MTC): Please indicate (S), (I) or (R) Streptomycin l Isoniazid l Rifampicin l Ethambutol l Pyrazinamide l Comments: (Please fill in as much detail as possible) ___________________________________________________________________________ *, Please contact the IMRL before dispatching a positive cultu ">@BDHdfhlxz|~ " \ ^ |   # [ Ջsokgkkh<hDKhoshh`5CJaJhkp'ho hh5CJaJh)*ChfHq h)*Ch6fHq h)*Ch`fHq h6hnRh6CJ4aJ4hbChb{hb{5CJ(aJ(h 0h8hu5>*CJ\aJh8h`5h`("^  [ % { b NFHx 9r gd  9r X d0gd x@  9r dhgd<  9r dXgdo  9r dXgd x@  9r dgd6  9r dgd8 9r [ b c d n $ % 9 : N h i z {          < > ` b l ( Nnz¹ֵ¹ֱ⦢ڞښ *ho ho h8ho h2 h2h2huhhp h<5CJ(aJ(hb{hb{5CJ(aJ(h h x@h<h`h6hkp' *hjhj>* *hjhjhjh9DFH ,028LPRVXptvxzȼ~wpll~h6 hjho hjhjhj hjh`h8CJ4aJ4h8CJ(aJ(hp5CJ(aJ( hnRhnRhb{ h 0hnhpCJ(aJ(hb{hb{5CJ(aJ(hph8hTCJ4aJ4hTh x@h8 hnRhnhh * *ho ho *ho *xz>@B$&(*,.0$ 9r dX$Ifa$gdYS6 9r dXgd^u 9r dXgdj 9r gd 9r -DM gd)*C 9r gd>@Bt"$&(*,.02468DԼ԰}sssslsss hX&5CJhYS6h"+5CJhYS6hTV>*hYS6h]5CJhYS6h8{5CJaJhYS6h]5CJaJhYS6h]CJhpEh^u>*CJaJhdh^u>*CJaJhUKh^u5>*CJh^u5>*CJaJhx6h^u5>*CJaJhhjUhh5&re for rapid molecular testing Please use the following table for Group Typing Requests: Referring laboratory:  Senders Phenotypic DST ResultsSurnameForenameHosp. No.Patient s ClinicianD.O.B.SexPatient s Address (mandatory for TB notification)Sender Lab No.Spec. typeSpec. dateSIREPIMRL Lab No.     Abbreviations: D.O.B., Date of birth; DST, drug susceptibility test, E, ethambutol; Hosp, Hospital; I, isoniazid, P, pyrazinamide; R, rifampicin; Spec, Specimen; S, streptomycin. Comments:     ST. JAMES S CENTRE FOR LABORATORY MEDICINE & MOLECULAR PATHOLOGY LF-IMRL-0070 Edition 08 Irish Mycobacteria Reference Laboratory POSITIVE Culture Request Form Ref: LM-IMRL-0006 Page  PAGE 2 of  NUMPAGES 2 0246` ~ $ 9r $Ifa$gdYS6 9r $IfgdYS6Ff 9r dX$IfgdYS6$ 9r dX$Ifa$gdYS6  ^ ` ~ !!!!! ! !!!!!!!!!! !"!$!&!(!*!,!.!κhYS6h8{>*CJhYS6h]>*CJhYS6h"+>*CJhYS6h8{>*hYS6h]5CJaJhYS6h"+5CJaJhYS6h"+5CJ hX&5CJ *ho 5CJ *hYS6h"+5CJ=  9r dh$IfgdYS6Ff`$ 9r x$Ifa$gdYS6$ 9r $Ifa$gdYS6$ 9r q$If]qa$gdYS6 !!!!! ! !!!!!!!!!! !"!$!FfV  9r dh$IfgdYS6$!&!(!*!,!.!0!2!4!6!8!:!!@!B!D!F!H!J!L!N!P!R!T!V!Ff6 9r dh$IfgdYS6FfH.!0!2!4!6!8!:!!@!B!D!F!H!J!L!N!P!R!T!V!X!Z!\!^!`!b!d!f!h!j!l!n!p!r!t!v!x!z!|!~!!!!!!!!!!!!!!!"""#######ȶ h7h2h^u h,Ah^u"jh^uCJUmHnHtH uh^uCJaJh8{CJaJh.MJh^uCJaJhYS6h8{>*CJhYS6h8{>*hYS6h"+>*CJ@V!X!Z!\!^!`!b!d!f!h!j!l!n!p!r!t!v!x!z!|!~!!!!!!!Ff$ 9r dh$IfgdYS6!!!!!!!!"## #"#&#(#,#.#2#4###r$t$ $ r dha$$dha$ 9r gd^uFf$ 9r dh$IfgdYS6## #"#$#&#(#*#,#.#0#2#4#L#b########$ $6$F$H$V$p$r$t$$$$洧暉uqqjc[h`mH sH  h`6CJ hMb6CJh`'h2)h2)5B*CJ\mH phsH !h65B*CJ\mH phsH h2)5CJ\mH sH h x@5CJ\mH sH h65CJ\mH sH h`5\mH sH h?)5CJ\mH sH h^5CJ\mH sH h`5CJ\mH sH hjhU!$$$$$$$$$$$$$$$$ h7h2hh`h<mHnHsH uh`mH sH jh`UmH sH t$$$$$ 9r gd^u 9r %9$d N gdMb9 0&P 1h:pos. A!"#$7% 9&P 1h0:p"+A .!7"#$%T $$If!v h#vh#vn#v#vn#v#v #v#v #v :V l3 t0=5h5n55n55 55 5 / / /  / pdyto kd$$Ifl3 j B#)h-w=h n n  n       t0=((((44 lapdyto B$$If!vh#vh#vn#v#vn#v#v #v#v #v R#v #v #v #v #v#v3:V l t0=5h5n55n55 55 5 R5 5 5 5 553/  / / / /  /  / p֠ytX&kd$$Ifldj B#)h-012 4(5D6w=h  n n  n     R      3   t0=@@@@44 lap֠ytX&B$$If!vh#vh#vn#v#vn#v#v #v#v #v R#v #v #v #v #v#v3:V l t0=5h5n55n55 55 5 R5 5 5 5 553/  / / / / / /  p֠ytX&kd $$Ifldj B#)h-012 4(5D6w=h nnn R3  t0=@@@@44 lap֠ytX&>$$If!vh#vh#vn#v#vn#v#v #v#v #v R#v #v #v #v #v#v3:V l t0=5h5n55n55 55 5 R5 5 5 5 553/  / / / / / /  p֠ytX&kd$$Ifldj B#)h-012 4(5D6w=h nnn R3  t0=@@@@44 lap֠ytX&>$$If!vh#vh#vn#v#vn#v#v #v#v #v R#v #v #v #v #v#v3:V l t0=5h5n55n55 55 5 R5 5 5 5 553/  / / / / / /  p֠ytX&kd$$Ifldj B#)h-012 4(5D6w=h nnn R3  t0=@@@@44 lap֠ytX&>$$If!vh#vh#vn#v#vn#v#v #v#v #v R#v #v #v #v #v#v3:V l t0=5h5n55n55 55 5 R5 5 5 5 553/  / / / / / /  p֠ytX&kd$$Ifldj B#)h-012 4(5D6w=h nnn R3  t0=@@@@44 lap֠ytX&>$$If!vh#vh#vn#v#vn#v#v #v#v #v R#v #v #v #v #v#v3:V l t0=5h5n55n55 55 5 R5 5 5 5 553/  / / / / / /  p֠ytX&kd!$$Ifldj B#)h-012 4(5D6w=h nnn R3  t0=@@@@44 lap֠ytX&x2&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH HH  Heading 1$$ @&a$5\\\  Heading 2$<@& 56CJOJQJ\]^JaJDA D Default Paragraph FontVi@V  Table Normal :V 44 la (k (No List :>: Title$a$ 5>*CJ \:J: Subtitle 5>*CJ \4@4 Header  9r 4 @"4 Footer  9r 828 kate$a$5\mH sH NCBN Body Text Indentdh^tH NPRN Body Text 25$7$8$9DH$ aJmH sH HbH u Balloon TextCJOJQJ^JaJjsj ^u Table Grid7:V0PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vj\{cp/IDg6wZ0s=Dĵw %;r,qlEآyDQ"Q,=c8B,!gxMD&铁M./SAe^QשF½|SˌDإbj|E7C<bʼNpr8fnߧFrI.{1fVԅ$21(t}kJV1/ ÚQL×07#]fVIhcMZ6/Hߏ bW`Gv Ts'BCt!LQ#JxݴyJ] C:= ċ(tRQ;^e1/-/A_Y)^6(p[_&N}njzb\->;nVb*.7p]M|MMM# ud9c47=iV7̪~㦓ødfÕ 5j z'^9J{rJЃ3Ax| FU9…i3Q/B)LʾRPx)04N O'> agYeHj*kblC=hPW!alfpX OAXl:XVZbr Zy4Sw3?WӊhPxzSq]y  <;< [ .!#$$ x0 $!V!!t$$ !@  @H 0(  N (  VB   C D"?VB   C D"?B S  ? >=>t 8"x<"t !/V*,-/02356  3</;*,-/02356  3333346>>?CI\]_fgb9:hi{""s>?@..``hh)**,--/02356Bvw  46>>?CI\]_fgb9:hi{""s>?@..``hh)**,--/02356Bv   ZO^`OJPJQJ^Jo(^`OJQJ^Jo(hHop^p`OJQJo(hH@ ^@ `OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHoP^P`OJQJo(hH ZO         HG o p 7]Qdy$X&kp'?)H)"+I-iT082YS6B8 x@)*C+EKDKlMb!]Mbmjn^u^<j?@ABCDEFGHJKLMNOPRSTUVWX[\_Root Entry F`y~^@Data '1Table3R+WordDocument v<SummaryInformation(IDocumentSummaryInformation8QMsoDataStore<y~y~L535I41A4MVQ==2<y~y~Item  2PropertiesUCompObj r   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q