Form 2a. NTP Laboratory Request and Result Form To be ited out by Heattn Worker Name of Requesting Facility: Date of Request: Faaility Contact information: Requesting Physician: Name of Patient: age: Sec | IM 1F Address: Patient's Contact No. Reasonfor | Ze History of Treatment: [|New If for Diagnosis or Baseline, Examination: Hee [ TRetreatment Registration Group: 1 1Baseline iNew [| tar { JRelapse { JpTOU 18 Case No: ‘ollow TALE ur mo For PMDT, month of treatment: ZF Specimen Type: { ISputum Repeat Collection? | Jo { ] Other (specify): T TY¥es Reason: DateSpecimen Collected: [Specimen Date of Collection for xpert. OST or UPA Presumptive 05-18 {|} 2 Presumptive ORTS [J Test Requested: [_{ 1ossm [1 Ixpertmre/nir | iculture tiost | {1a 1 for Xpert, SSM Result If for DST, Xpert Result for OST, HIV Result. Prepared by: Position: ‘Sgrature over Printed Nome ‘Porton below to be filed out by Medical Technolapat/MiroscopaWXpen Technican —— $$$ ————————————— Laboratory Serial Number Date Received: Date Examined: LABORATORY TEST Xpert MTB/RIF FINDINGS nvonan tv cot oppo eons "Meena bose Renee Fone oe Date of Release “Signature over Prited Wome ‘A seporote resvit form for TB Culture, OST and LPA wil be sued