Form 3a.

Laboratory Register for Xpert MTB/RIF

Name of Facility: 

Province/ HUC: 

Region: 

Cohort: 
 Cartridges Xpert Signature of
Date and Used MTB/RIF Result Laboratory Staff
Date Name of Patient's Full Name History of
Laboratory Time Xpert
Specimen Requesting (SURNAME, Given Names, Age Treatment Xpert Remarks
Serial Number Specimen Sex MTB/ Date Specimen Date and Time
Collected Facility/Unit Name Extension, Middle Name) (N/R) MTB/
Received RIF Examined Released
RIF
(M/F) Ultra
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12)

10

Form 3a. Laboratory Register for Xpert MTB/RIF v.030420