NOVEL INFLUENZA A (H1N1) TEST REQUEST FORM STATE OF ... 2026

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The document is a test request form for the Novel Influenza A (H1N1) at the Utah Public Health Laboratories. It outlines the necessary patient and provider information, specimen collection details, and specific clinical criteria that must be met for testing eligibility. The form emphasizes that testing is limited to patients with severe illness or certain high-risk groups due to equipment and supply constraints.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the 'Patient Information' section. Enter the patient's name, ID number, date of birth, age, and sex clearly.
Next, complete the 'Provider Information' section. Input the provider code, physician's name, phone number, email address, and secure fax number.
In the 'Specimen' section, indicate the collection date and select the specimen source/site from the provided options.
For 'Clinical/Epidemiologic Criteria for Testing', ensure you check all applicable criteria that justify testing for Novel Influenza A (H1N1).
Review all entries for accuracy before submitting. Ensure that every field is filled out completely as testing will not be performed unless this form is fully completed.

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