Public Health Laboratory Documents and Forms

• PDF [536KB] 
  Clinical Specimen Submission Requisition PDF [536KB] 
  Form 1252
• PDF [337KB] 
  Clinical Select Agent Rule-Out Submission Requisition PDF [337KB] 
• PDF [152KB] 
  SARS-CoV-2 (COVID-19) Testing Requisition and Shipping Guidelines PDF [152KB] 
  Form 1198
• PDF [45KB] 
  Submission Form for Mosquito Testing PDF [45KB] 
  Form 1140
• PDF [79KB] 
  CRE and CRPA Isolate Submission Requisition PDF [79KB] 
  Form 1042
• PDF [141KB] 
  Arbovirus Panel Request Form PDF [141KB] 
  Form 8021
• PDF [83KB] 
  HIV Antibody Request Form PDF [83KB] 
  Form 364
• PDF [212KB] 
  Influenza Testing Request Form PDF [212KB] 
  Form 930
• PDF [139KB] 
  Miscellaneous Laboratory Examination Request Form PDF [139KB] 
  Form 402
• PDF [118KB] 
  Mycobacteriology Culture Request Form PDF [118KB] 
  Form 416
• PDF [57KB] 
  TB EIA (QuantiFERON Gold In-Tube) Request Form PDF [57KB] 
  Form 493
• PDF [154KB] 
  Rabies Test Request Form PDF [154KB] 
  Form 433

• PDF [134KB] 
  Dairy Water Microbiology Monitoring Sample Request Form PDF [134KB] 
  Form 146
• PDF [190KB] 
  Bottled Water or Ice Microbiology Request Form PDF [190KB] 
  Form 411
• PDF [129KB] 
  Drinking Water Fluoride Request Form PDF [129KB] 
  Form 428
• PDF [183KB] 
  Drinking Water Microbiology Request Form PDF [183KB] 
  Form 425
• PDF [147KB] 
  Drinking Water Microbiology Monitoring Sample Request Form PDF [147KB] 
  Form 427

• PDF [383KB] 
  First Responder Specimen Collection Guide PDF [383KB] 
• PDF [1MB] 
  First Responder/HAZMAT Field Testing for Environmental Samples PDF [1MB] 
  Form 397
• PDF [98KB] 
  MPHL Clinical Sample Submission Guidelines for Bioterrorism Agents PDF [98KB] 
  June 2013
• PDF [109KB] 
  MPHL Clinical Sample Submission Guidelines for Chemical Terrorism Agents PDF [109KB] 
  June 2013
• PDF [138KB] 
  Specimen Collection Flowchart for Chemical Exposure Event PDF [138KB] 
  CDC
• PDF [87KB] 
  Shipping Instructions for Specimens Collected from People Who May Have Been Exposed to Chemical Terrorism Agents PDF [87KB] 
  CDC
• PDF [197KB] 
  Shipping Blood Specimens to CDC after a Chemical Exposure Event PDF [197KB] 
  CDC
• PDF [233KB] 
  Shipping Urine Specimens to CDC after a Chemical Exposure Event PDF [233KB] 
  CDC
• PDF [58KB] 
  Chemical Terrorism Blood Specimen Collection and Shipping Manifest PDF [58KB] 
  CDC
• PDF [41KB] 
  Chemical Terrorism Urine Specimen Collection and Shipping Manifest PDF [41KB] 
  CDC

• PDF [203KB] 
  MPHL CLIA Certificate of Compliance PDF [203KB] 
  Valid through April 2028

• PDF [2MB] 
  Recognize. Rule-Out. Refer: Biothreat Agent Bench Cards for the Sentinel Clinical Laboratory PDF [2MB] 
  September 2021
• PDF [16MB] 
  Mississippi Clinical Laboratory Preparedness and Response Guide PDF [16MB] 
  May 2018

• PDF [3MB] 
  Laboratory Services Guide, Appendix C, Rabies Testing PDF [3MB] 
  November 2016
• PDF [167KB] 
  Zika Virus Test Requisition PDF [167KB] 
  November 2016
• PDF [215KB] 
  Patient Request for Release of Completed Laboratory Results PDF [215KB] 
  Form AS0-1-0

Mississippi State Department of Health • 570 East Woodrow Wilson Dr • Jackson, MS 39216 • 866‑HLTHY4U • Contact and information