Alaska Tuberculosis Program Manual - Epidemiology - State of Alaska

ALASKA STATE
PUBLIC HEALTH LABORATORY
TB PCR Testing Authorization form
5455 Dr. Martin Luther King Jr.
Anchorage, AK 99507
Phone: 907-334-2139 (TB Dept)
FAX: 907-334-2161
The Alaska State Public Health Laboratory (ASPHL) has developed a nucleic acid amplification assay by
real-time polymerase chain reaction (PCR) for use on respiratory specimens for the diagnosis of
tuberculosis (TB). This assay was developed and its performance characteristics were determined by
ASPHL. This assay has not been cleared by the U.S. Food and Drug Administration.
The CDC recommends this type of testing be performed on at least one AFB smear positive respiratory
specimen from each patient with signs and symptoms of pulmonary TB for whom a diagnosis of TB is
being considered but has not yet been established, and for whom the test result would alter case
management or TB control activities, such as contact investigations.
Patient Criteria:
Patient must have signs and symptoms of pulmonary TB
Patient must be reported to the Alaska Tuberculosis Control Program as a suspect TB case
(907-269-8000)
Patient must not have been diagnosed with TB or a non-tuberculous mycobacterial infection or
received treatment within the last 12 months
Patient Name AFB Smear Results:
DOB: Collection Date:
Please answer the following questions. Circle Response
Yes No Unknown Does the patient have signs and symptoms of pulmonary TB?
Yes No Unknown
Has the patient been diagnosed with TB or a non-tuberculous mycobacterial infection
within the last 12 months?
Yes No Unknown Has the patient received anti-TB treatment within the last 12 months?
Yes No Unknown Is the patient a contact of a positive TB case?
Yes No Unknown Abnormal Chest X-Ray?
Yes No Unknown Skin test Positive?
Pos Neg Unknown
Not Done
Quantiferon TB Gold Test Result?
I _____Authorize ASPHL to perform TB PCR testing.
I _____DO NOT Authorize ASPHL to perform TB PCR testing.
The cost for testing is $153 and fees for service will be billed to the facility submitting the specimen.
Clinician Printed Name:_____________________________________ Date:______________________
Clinician Signature:_________________________________________
Please fax completed authorization to 907-334-2161 Attn: TB Department 2/2012