Healthcare Water Cultures Form

HEALTHCARE WATER CULTURES FORM

Purpose: Use this form to request microbiological culture and related testing of water samples associated with patient care areas, patient exposures, or environmental surveillance. By signing, the patient (or authorized representative) authorizes collection of samples from the specified site(s), laboratory testing, and the release of results to the ordering facility, treating clinician, and public health authorities as required by law.

Patient Information

Date of Birth:

Facility and Requesting Clinician

Clinical Risk Factors

Immunocompromised Current infection possibly linked to water On dialysis

Central vascular access Mechanically ventilated Recent transplant

Sample Collection Details

Sample 1

Collection Date: Time:

Additional Samples (Sample 2, 3, 4) — replicate fields as needed

Tests Requested

Legionella culture Legionella PCR (molecular) Heterotrophic Plate Count (HPC)

Mycobacterial culture Fungal culture Pseudomonas assay

Reason for Testing

Outbreak / exposure investigation Routine surveillance Post-remediation clearance

Construction or plumbing work Patient exposure / clinical correlation Other

Chain of Custody and Submission

Shipment Date: Time:

Authorization and Release

By signing below, the patient or authorized representative authorizes collection of water samples at the locations specified above and consents to laboratory testing as requested. The patient authorizes the release of test results, interpretations, and associated protected health information to the ordering clinician, the facility, and to local and state public health authorities where disclosure is required by law. The undersigned acknowledges that laboratory methods have inherent limits and that sample collection, handling, and environmental variability can affect results. The laboratory and facility will make reasonable efforts to ensure chain of custody and specimen integrity but shall not be liable for losses or damages resulting from improper or delayed sampling, transport, or handling outside reasonable control.

This authorization expires on the date specified below or upon completion of the requested testing and reporting unless revoked in writing prior to that time. Revocation will not apply to disclosures already made in reliance on this authorization.

Acknowledgement: I acknowledge and consent to the terms above regarding testing and release of results.

Laboratory Use / Notes

I certify that I collected the specimens listed above in accordance with the facility sampling protocol and documented the date and time of collection.

Collector Date:

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