MDH Infectious Disease Lab Supply Order Form
Contact and Shipping Information (all fields required)
Name
Facility Name
Street Address (No PO Box)
City
State
Undecided
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Outside the United States
Zip code
Phone Number (for questions about this order)
Please answer question 5 (Name) before continuing.
Please answer question 5 (Facility Name) before continuing.
Please answer question 5 (Street Address (No PO Box)) before continuing.
Please answer question 5 (City) before continuing.
Please answer question 5 (State) before continuing.
Please answer question 5 (Zip code) before continuing.
Your answer to question 5 (Zip code) must be a valid ZIP Code.
Please answer question 5 (Phone Number (for questions about this order)) before continuing.
Biological Substance Category A Mailers (Maximum order is 5)
Large box for plates and slants
Small box for slants only
Your answer to question 7 (Large box for plates and slants) must be a whole number.
Your numeric answer does not fall within accepted range.
Your answer of %2 for question 7 (Large box for plates and slants) may only contain the following characters 012345.
For confirmation, the answer to 7 (Large box for plates and slants) must be less than %1.
Your answer to question 7 (Small box for slants only) must be a whole number.
Your numeric answer does not fall within accepted range.
Biological Substance Category B Mailers
Brown box w/Tyvek envelope & bag for plates or slants
White box w/plastic cylinder for slants only
Double cylinder (use with private courier only) for slants
Box for Plates
Your answer to question 8 (Brown box w/Tyvek envelope & bag for plates or slants) must be a whole number.
Your numeric answer does not fall within accepted range.
Your answer to question 8 (White box w/plastic cylinder for slants only) must be a whole number.
Your numeric answer does not fall within accepted range.
Your answer to question 8 (Double cylinder (use with private courier only) for slants) must be a whole number.
Your numeric answer does not fall within accepted range.
Your answer to question 8 (Box for Plates) must be a whole number.
Your numeric answer does not fall within accepted range.
AFB Supplies
Double cylinder w/50 mL tube (use with private courier only)
50 mL tubes only
Small Cooler (includes ice pack) for 1-2 specimens (Public Health Agencies Only, max order 3 coolers)
Large Cooler (includes ice pack) for 3 specimens (Public Health Agencies Only, max order 1 cooler)
Your answer to question 1 (Double cylinder w/50 mL tube (use with private courier only)) must be a whole number.
Your numeric answer does not fall within accepted range.
Your answer to question 1 (50 mL tubes only) must be a whole number.
Your numeric answer does not fall within accepted range.
Your answer to question 1 (Small Cooler (includes ice pack) for 1-2 specimens (Public Health Agencies Only, max order 3 coolers)) must be a whole number.
Your numeric answer does not fall within accepted range.
Your answer to question 1 (Large Cooler (includes ice pack) for 3 specimens (Public Health Agencies Only, max order 1 cooler)) must be a whole number.
Your numeric answer does not fall within accepted range.
Project 840 Pertussis Supplies Only
Biological Substance Category B boxes and labels
Ice Packs
Nasopharyngeal Swabs
Vials of Regan-Lowe
Tyvek envelope & plastic bag
Your answer to question 3 (Biological Substance Category B boxes and labels) must be a whole number.
Your numeric answer does not fall within accepted range.
Your answer to question 3 (Ice Packs) must be a whole number.
Your numeric answer does not fall within accepted range.
Your answer to question 3 (Nasopharyngeal Swabs) must be a whole number.
Your numeric answer does not fall within accepted range.
Your answer to question 3 (Vials of Regan-Lowe) must be a whole number.
Your numeric answer does not fall within accepted range.
Your answer to question 3 (Tyvek envelope & plastic bag) must be a whole number.
Your numeric answer does not fall within accepted range.
Other
Diphtheria Kit (2 tubes Loeffler Media, 2 swabs)
Syphilis Serology - Biohazard Bags
Wang's Media
Absorbent sheets
Your answer to question 4 (Diphtheria Kit (2 tubes Loeffler Media, 2 swabs)) must be a whole number.
Your numeric answer does not fall within accepted range.
Your answer to question 4 (Syphilis Serology - Biohazard Bags) must be a whole number.
Your numeric answer does not fall within accepted range.
Your answer to question 4 (Wang's Media) must be a whole number.
Your numeric answer does not fall within accepted range.
Your answer to question 4 (Absorbent sheets) must be a whole number.
Your numeric answer does not fall within accepted range.
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