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Acute Services Division
MAN-F-265
Diagnostics Directorate
West of Scotland Specialist Virology Centre
Level 5, New Lister Building
Glasgow Royal Infirmary
10-16 Alexandra Parade
Glasgow, G31 2ER
Version 6 – 6th JUNE 2016
WoSSVC Lab No:
REQUEST FORM: Hepatitis B DNA testing for healthcare workers involved in EPP in
accordance with Department of Health guidelines
Please send TWO x 9ml blood in an EDTA bottle to West of Scotland Specialist Virology Centre, Level 5, New Lister
Building, Glasgow Royal Infirmary, Glasgow, G31 2ER (Hays DX 6491304, Exchange Glasgow 94G)
Tel: 0141 201 8722 Email: Dr Eleri Wilson-Davies ([email protected])
Occuptional Health Contact Name:
Name & address for Result
Occuptional Health Contact Tel:
_________________________________________
Occuptional Health Contact Email:
_________________________________________
_________________________________________
ID / NHS / CHI No: ___________________________
_________________________________________
Patient Surname _____________________________
_________________________________________
Patient Forename ____________________________
Name & address for Invoice
D.O.B. _____/______/________ Gender Male/Female
_________________________________________
Requesting physician: _________________________
_________________________________________
Specimen type: 9ml EDTA blood bottle x2
_________________________________________
Requesting Lab No: ___________________________
_________________________________________
Date sample collected _____/______/________
_________________________________________
Time sample collected __________________am / pm
SECTION 2: TESTING (Tick the appropriate box)
FIRST ASSESSMENT OF HBV POSITIVE HCW FOR EPP: Two samples taken MORE than one
month apart.
FIRST SAMPLE / SECOND SAMPLE (Delete as appropriate)
SECTION 2: If this patient is on treatment please give details inc antiviral drug, duration, when the
ANNUAL FOLLOW UP OF HCW NOT ON TREATMENT (PREVIOUSLY ASSESSED FOR
treatment
completed,
as appropriate
your
patient.
EPP): Twowas
samples
taken between
one weektoand
one
month apart.
FIRST SAMPLE / SECOND SAMPLE (Delete as appropriate)
FIRST ASSESSMENT OF HCW ON APPROPRIATE ANTI-VIRAL TREATMENT FOR EPP:
Two samples taken MORE than one month apart.
FIRST SAMPLE / SECOND SAMPLE (Delete as appropriate)
HCW CURRENTLY ON APPROPRIATE ANTI-VIRAL TREATMENT PREVIOUSLY
ASSESSED FOR EPP: Checked every three months (the period should be taken from the date the previous
blood sample was drawn, and not from the date the result was received).
OTHER: _______________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
(FULL DETAILS REQUIRED OR TESTING WILL NOT BE PERFORMED)
Delivering better health
www.nhsggc.org.uk
Tel: +44(0) 141-201 8722
Fax: +44(0) 141-201 8723
[email protected] http://www.nhsggc.org.uk/virology
Clinical Lead for Virology: Celia Aitken
Consultant Medical Virologist: Eleri Wilson-Davies
Consultant Clinical Scientist: Rory Gunson
Technical Services Manager: Stephen Hughes
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