Tarrant County Public Health Department North Texas Regional Laboratory 1101 S Main St Forth Worth TX 76104 Instructions for Submitting Isolate for Pulse Field Gel Electrophoresis 1 Include

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Tarrant County Public Health Department North Texas Regional Laboratory 1101 S Main St Forth Worth TX 76104 Instructions for Submitting Isolate for Pulse Field Gel Electrophoresis 1 Include Powered By Docstoc
					                                        Tarrant County Public Health Department
                                            North Texas Regional Laboratory
                                                    1101 S. Main St.
                                                 Forth Worth, TX 76104




            Instructions for Submitting Isolate for Pulse Field Gel Electrophoresis


   1) Include all information requested on the PFGE submission form. If an outbreak is suspected,
      please contact the Epidemiology Division at Tarrant County Public Health (817-253-1129) for
      additional information. Please complete the Patient History Form for all outbreak suspected
      cases; a minimum of two different isolates from different sources must be submitted for
      outbreak investigation.

   2) All isolates submitted for PFGE molecular typing must be identified at the genus level. Please
      provide where available any additional information regarding species, serotype, toxin profile,
      phage type, biochemical profile and antibiotic profile.

   3) All cultures submitted to The Tarrant County Department of Public Health laboratory should be
      shipped to the laboratory according to Department of Transportation (DOT) or International Air
      Transport Association (IATA) shipping and packaging regulations for diagnostic or infectious
      substances.

   4) Results of laboratory testing will be released to the entity submitting the isolate within 14 days.


The following Tarrant County Public Health microbiologists can accept isolates for PFGE molecular
subtyping:


   Jason Nagati
   Work: (817) 321-4771

   Diana Cervantes
   Work: (817) 321-4765
   Cell (24/ 7): (817) 846-6708
                                                                            PFGE Lab ID
                   Tarrant County Public Health Department                  Date Received
                   North Texas Regional Laboratory
                   BT Response/Emerging Agents Unit                         Received by




                                   PFGE Isolate Submission Form


   I.       Submitting Agency Information

    Date


        Hospital or
        Laboratory Name

                   Address:                           City:                        State:     Zip code:

        Location



        Name and Title of person
        submitting sample



                                    Phone:                           Fax:
           Contact Information



   II.      Patient Information

                        Last:                      Middle:       First:
    Patient Name


        Date of
        Birth

   III.     Sample Information

    Hospital or Clinical                                 Date of
    Laboratory ID                                        Isolation



PFGE Form 001                                                                             Revised 01/07/2008
Isolate Origin
                       □ Human □ Animal (specify)________________
                       □ Other (specify)_____________________
Outbreak               □ Yes □ No (Please note at least two isolates must be submitted for outbreak
Investigation?         investigation)
Isolate
Identification:
                       □ Escherichia coli         □ Shigella spp.            □ Salmonella spp.         □ Listeria spp,

No. times
isolated


Sample Type or Source: Check applicable type/source
□ Feces                             □ Urine
                                                                            Submitted On:
□ Blood/Serum                       □ Sputum                                Media
                                                                                             Container          Number of
                                                                                             Type               containers
□ Skin or wound                     □ Bone
scrapings
□ Bone Marrow                       □   Organs biopsied/
                                    tissue specimens
□ Cerebrospinal fluid               □   Swabs from eyes, skin
                                    lesions, or ulcers
□ Lung Aspirate                     □   Food (please provide
                                    specific info in patient
                                    history form)
□Bronchial/tracheal swabs □ Other, please specify


   IV.      Submitting Agency Laboratory Results
   Previous laboratory tests and results/ other clinical Information:

   □ Species                 Result _______________              Any other microbiological tests performed on
   □ Sub-species             Result_______________               isolate and results:
   □ Serotype                Result_______________
   □ Phage Type              Result_______________
   □ Toxin Type               Result_______________
   □ Antibiotic Profile       Result_______________
   □ Biochemical Profile      Result_______________



PFGE Form 001                                                                                     Revised 01/07/2008
                              PATIENT HISTORY

Date of Onset: ____/_____/________

Clinical Symptoms: _____________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Patient Travel History (include Dates): ______________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Food Exposure Information: ______________________________________________

_____________________________________________________________________

Other Exposure Information: ______________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________