National Salmonella, Shigella & Listeria Reference Laboratory, Department of Medical Microbiology, GUH, (091) 544628 NSSLRL Use Only NSSLRL number NSSLRL APEX NSSLRL Receipt Date Senders Information *Referring Laboratory: *Contact Name & Number (Clinical microbiologist) *Sender’s Reference Number: * Primary Sample Date: *Isolate Details: Isolation Date (optional) Salmonella Shigella Listeria⁪ ⁪ ⁪ Senders Lab Findings: * If you suspect the specimen requires handling at CL 3 please tick ? Typhi ? Paratyphi ? S. S. Shigella dysenteriae ⁪ ⁪ ⁪ Non-Human Isolates * Live Animal: Bovine Swine Poultry ⁪ ⁪ ⁪ * Food: Bovine Swine Poultry ⁪ ⁪ ⁪ * Source/ Environmental: (please specify) Human Isolates * Surname: * First Name: * D.O.B: * Sex: M F⁪ Unknown⁪ ⁪ Address: Clinical/ Epidemiological information: Foreign travel (State country) Animal contact (please specify) Outbreak Associated(please specify) ⁪ ⁪ ⁪ mode, e.g. Implicated food, person-to-person ⁪Transmission * Isolate Source: Other (please specify) ⁪Faeces ⁪Blood ⁪CSF ⁪ * All these fields are compulsory to comply with minimum laboratory requirements
National Salmonella, Shigella & Listeria Reference Laboratory, Department of Medical Microbiology, GUH, (091) 544628 NSSLRL Use Only NSSLRL number NSSLRL Receipt Date NSSLRL APEX Senders Information *Referring Laboratory: *Contact Name & Number (Clinical microbiologist) *Sender’s Reference Number: * Primary Sample Date: *Isolate Details: Salmonella ⁪ Shigella ⁪ Listeria⁪ Isolation Date (optional) Senders Lab Findings: * If you suspect the specimen requires handling at CL 3 please tick ⁪ ? S. Typhi ⁪ ? S. Paratyphi ⁪ ? Shigella dysenteriae Non-Human Isolates * Live Animal: Bovine ⁪ Swine ⁪ Poultry ⁪ * Food: Bovine ⁪ Swine ⁪ Poultry ⁪ * Source/ Environmental: (please specify) Human Isolates * Surname: * First Name: * D.O.B: * Sex: M ⁪ F⁪ Unknown⁪ Address: Clinical/ Epidemiological information: ⁪ Foreign travel (State country) ⁪ Animal contact (please specify) ⁪ Outbreak Associated(please specify) ⁪Transmission mode, e.g. Implicated food, person-to-person * Isolate Source: ⁪Faeces ⁪Blood ⁪CSF ⁪ Other (please specify) * All these fields are compulsory to comply with minimum laboratory requirements