FORM 2D.

TB CULTURE RESULT FORM

TB Case Number:  Date of Request: 

Name of Requesting Facility/Unit:  Requesting Physician: 
Patient’ Full Name:  Name of Laboratory: 
Age:  Sex:  [  ] M  [  ] F

Reason for Examination: [  ] Baseline [  ] Follow-up; month:  [  ] Diagnosis

Type of Specimen: [  ] Sputum [  ] Others (specify): 
Method: [  ] Solid Culture [  ] Liquid Culture: MGIT

Date Specimen Date and Time

TB Culture Laboratory Number TB Culture Result
Collected Specimen Received
1

Remarks:  Date and Time Released: 

Performed by: Verified by: Noted by:

Signature over Printed Name Signature over Printed Name Signature over Printed Name

Form 2d. TB Culture Result Form  v. 050120