UW Medicine Anatomic Pathology Specimen Collection Manual

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UW Medicine Pathology Mission Statement

The Division of Anatomic Pathology is committed to excellence in the diagnosis of human disease. Our department and team members are committed to:

• Delivering timely and accurate diagnoses that support outstanding patient care and inform effective and appropriate treatment options for patients. • Providing fellows, residents and medical school students with exceptional education and experience, creating leaders within pathology and within healthcare. • Striving to provide educational services within UWMC that enhance the clinical expertise of our medical colleagues and promote the advancement of medical knowledge through basic and clinical research. • Employing compassion throughout all diagnostic services. • Focusing on patient and employee safety and on quality. UW Medicine Pathology Vision Statement

The Division of Anatomic Pathology is a recognized leader in quality diagnostic services, state of the art research, comprehensive teaching and is engaged in continually evolving methods to offer excellent and meaningful diagnoses.

Contents

General Information ...... 1-1 1.1 Laboratory Contact Information ...... 1-1 1.2 Specimen Labeling and Submission ...... 1-2 1.3 Specimen Rejection ...... 1-3 Gynecological Cytology Service ...... 2-1 2.1 Gynecological ThinPrep Pap Test ...... 2-1 Non-Gyn Cytology Services ...... 3-1 3.1 Bladder Washing ...... 3-1 3.2 Body Cavity Fluid (peritoneal wash, pleural ascites, pericardial, etc.) ...... 3-2 3.3 Bronchial Brushing ...... 3-3 3.4 Bronchial Washing ...... 3-4 3.5 Cerebrospinal Fluid (CSF) ...... 3-5 3.6 Fine Needle Aspiration (FNA) ...... 3-6 3.7 Miscellaneous Aspiration (Cysts, Joints, Etc) ...... 3-7 3.8 Miscellaneous Brushing (Renal, Gastric, Common Bile Duct, Endocervical Cytobrush, Etc) ..... 3-8 3.9 Sputum ...... 3-9 3.10 Sputum for PCP ...... 3-10 3.11 Thyroid Aspirate ...... 3-11 3.12 Urine – Voided ...... 3-12 3.13 Urine – Catheterized ...... 3-13 Molecular Diagnostics Services ...... 4-1 4.1 Human Papilloma Virus (GYN in ThinPrep Pap Test Media) ...... 4-1 4.1.1 GYN in SurePath Media ...... 4-2 4.1.2 GYN in Qiagen Specimen Transport Media (STM) ...... 4-3 4.1.3 Anal in Qiagen Specimen Transport Media (STM) ...... 4-4 4.1.4 Anal in ThinPrep Media ...... 4-5 Histology Services ...... 5-1 5.1 Frozen Sections UWMC-MT ...... 5-1 5.2 Frozen Sections UWMC-NW ...... 5-2 5.3 Frozen Sections HMC ...... 5-3 5.4 Gross Examination ...... 5-4 ii

5.5 Bone Marrow Biopsy Specimens ...... 5-5 5.6 Renal Biopsy Specimens ...... 5-6 5.7 Surgical Tissue Specimens ...... 5-7 5.8 Tissue Biopsy Specimens ...... 5-8 Neuropathology Services ...... 6-1 6.1 Brain/Spine Biopsy Specimens ...... 6-1 6.2 Brain Tumor Specimen for Fluorescent In Situ Hybridization (FISH) ...... 6-2 6.3 Muscle Specimens ...... 6-3 6.4 Nerve Specimens...... 6-4 6.5 Ocular Biopsy Specimens ...... 6-5 Immunofluorescence ...... 7-1 7.1 Direct Immunofluorescence ...... 7-1 7.1.1 Oral Biopsy Specimens ...... 7-1 7.1.2 Skin Specimens ...... 7-2 7.2 In-Direct Immunofluorescence ...... 7-3 7.2.1 Serum Specimen ...... 7-3 Cytogenetics Services...... 8-1 8.1 Amniotic Fluid ...... 8-1 8.2 Bone Marrow / Oncology Blood ...... 8-2 8.3 Chorionic Villi ...... 8-3 8.4 DNA Samples ...... 8-4 8.5 Peripheral Blood ...... 8-5 8.6 Solid Tissue (including Products of Conception, Skin Biopsies, Stillbirths) ...... 8-6 8.7 Urine...... 8-7 8.8 Biliary Duct Brushing ...... 8-8 Additional Testing Services ...... 9-1 9.1 Electron Microscopy Services: ...... 9-1 9.2 DNA Flow Cytometry ...... 9-2 Outside Slides/Block Review Services ...... 10-1 10.1 Slide Reviews (UW Medicine Patients) ...... 10-1 Slide Consults (External consultation with UW Medicine Pathologists) ...... 10-1 Requisitions/Forms...... 11-1

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General Information 1.1 Laboratory Contact Information

Harborview Medical Center Ninth and Jefferson Building – 2nd Floor (2NJB-244) Telephone: (206) 744-3145 Fax: (206) 744-8240

University of Washington Medical Center – Montlake 2nd Floor (BB220) Telephone: (206) 598-6400 Fax: (206) 598-5068

University of Washington Medical Center – NW 1550 N 115th St, #A-220 Telephone: (206) 668-1779 Fax: (206) 668-1163

1-1 1.2 Specimen Labeling and Submission The College of American Pathologists (CAP) and other accrediting agencies require strict adherence to specimen labeling and specimen submission guidelines. In order to avoid delays in testing, diagnosis and to prevent specimen rejection, the following requisition and specimen container requirements must be followed.

Requisition:

Patient’s First Name Patient’s Last Name Patient’s Middle Initial (if applicable) Patient’s Medical Record Number Patient’s Date of Birth Date of Specimen Collection Time of Specimen Collection Referring Providers Name Clinical Data including history, planned procedures and differential diagnosis (if applicable) Exact anatomical source/site, whenever possible Name and Contact Phone Number of Person Completing the Form

Specimen Container:

Patient’s First Name Patient’s Last Name Patient’s Middle Initial (if applicable) Patient Medical Record Number and/or Patient Date of Birth Exact anatomical source/site whenever possible

For Cytopathology:

Each prepared slide must be labeled separately and any specimen containers with patient materials must also be labeled correctly

For ALL specimens submitted to Anatomic Pathology:

All containers must be sealed appropriately to prevent loss of specimens and to reduce employee exposure to chemicals. Specimen containers must be completely sealed in order to ensure that specimens or collection media does not leak.

A common reason for specimen rejection is the incomplete or improper closure of caps on specimen collection containers, causing container leaks. This can result in loss of irretrievable specimens or unreadable specimen labels due to leaked fluid or collection media. Please double-check specimen collection containers in order to ensure containers are closed properly. Additionally, all specimen containers must be placed in a biohazard bag of appropriate size and a complete seal attained.

A report within the Patient Safety Network System (PSN) and/or the Laboratory Event Management System (LEMS), will be submitted for documentation, if insufficient specimen submission practices occur. 1-2 1.3 Specimen Rejection All specimens must be properly labeled in order to ensure patient safety and to prevent errors in diagnosis and treatment. Anatomic Pathology does not accept unlabeled and/or mislabeled specimens.

Definitions of Unlabeled and Mislabeled Specimens:

Unlabeled Specimen:

Specimen with no patient identifiers (i.e. patient name, patient medical record number)/specimen that has not been labeled.

Mislabeled Specimen:

Specimen that has not been labeled with two patient identifiers.

Specimen labeled with a patient name and/or medical record number that are different from that on the accompanying laboratory request form.

Specimen retrieved from correct patient but labeled with a wrong name and/or medical record number/date of birth.

1-3 Gynecological Cytology Service 2.1 Gynecological ThinPrep Pap Test

Day(s) / Time (s) Performed: Monday – Friday 8:00 am - 5:00 pm Turnaround Time**: 5 Business Days Specimen Collection Supplies: • ThinPrep Pap Test (PreservCyt) Vial (Not CytoLyt) • Plastic Spatula • Endocervical brush • Biohazard Safety Bag • Cytology Requisition

For Conventional Smear: • Glass Slide • 95% Ethanol Fixative • Specimen Collection Container Specimen Collection: Label vial with two patient identifiers. Obtain adequate sample from ectocervix and endocervical canal using plastic spatula and endocervical brush. Immediately rinse vigorously 10 times in solution to remove any residual sample from spatula and brush. Discard the collection device. Tighten cap and place vial and requisition in bag for transport to laboratory.

If conventional smear is desired, label glass slide and immediately place into 95% Ethanol fixative. Label fixative container, mark appropriate boxes on requisition, and place both in bag for transportation to laboratory. Specimen Handling: Room Temperature Specimen Requirements: • Label with two (2) patient identifiers • Completed Cytology Specimen Requisition Transportation: Deliver/send to laboratory as soon as possible Comments / Special Do not use formalin as a fixative Instructions: Rejection Criteria: • Inadequate Information/missing requisition • Unlabeled / Mislabeled Specimen • Specimen received in inappropriate fixative • Specimen received with collection device still in vial Retention Time of Specimen: Six (6) Weeks After Final Report is Issued Laboratory Subsection: Cytopathology - Harborview ** Turnaround times vary depending on multiple specimen and laboratory factors.

2-1 Non-Gyn Cytology Services 3.1 Bladder Washing

Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Turnaround Time**: 5 business days Specimen Collection Supplies: • Specimen Collection Container • Biohazard Safety Bag If delay is anticipated to be longer than 24 hours for delivery: • CytoLyt or 50% Ethanol Specimen Collection: Collect specimen and deliver fresh specimen to laboratory immediately.

If a delay of more than 24 hours to deliver is anticipated, add equal volume CytoLyt or 50% ethanol. Specimen Handling: Room Temperature if specimen is delivered upon collection.* *If slight delivery delay is anticipated, refrigerate *If a longer delivery delay is anticipated, add equal volume CytoLyt or 50% ethanol Specimen Requirements: • Label with two (2) patient identifiers • Completed Cytology Specimen Requisition Transportation: Deliver/send to laboratory as soon as possible Comments / Special Bladder washing is a valuable addition to cystoscopy in Instructions: symptomatic patients. Typically it is performed prior to cystoscopy with the injection of 50-75ml of physiological saline through a catheter or the cystoscope. Bladder visualization is performed by injecting water to dilate the bladder.

Cystoscopic examination should be performed after the irrigation for cytology, because water causes cellular degeneration. Highly cellular specimens are obtained in this manner. Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Specimen received in inappropriate fixative. Do not use formalin as a fixative. Retention Time of Specimen: One (1) Week After Final Report is Issued Laboratory Subsection: Cytopathology – Harborview ** Turnaround times vary depending on multiple specimen and laboratory factors.

3-1 3.2 Body Cavity Fluid (peritoneal wash, pleural ascites, pericardial, etc.)

Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00pm Turnaround Time**: 5 business days Specimen Collection Supplies: • EDTA or Sodium Heparin • Specimen Collection Container • Biohazard Safety Bag Specimen Collection: Optimum volume is 100-300ml (more if available).

For bloody specimens, add 0.5 EDTA or Sodium Heparin for every 100ml collected into a clean container. Specimen Handling: Room temperature if specimen is delivered upon collection* *If delivery delay is anticipated, refrigerate Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Cytology Specimen Requisition Transportation: Deliver/send to laboratory as soon as possible Comments / Special Do not use formalin as a fixative Instructions: Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Specimen received in inappropriate fixative. Do not use formalin as a fixative. Retention Time of Specimen: One (1) Week After Final Report is Issued Laboratory Subsection: Cytopathology - Harborview **Turnaround times vary depending on multiple specimen and laboratory factors.

3-2 3.3 Bronchial Brushing

Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Turnaround Time**: 5 business days Specimen Collection Supplies: • Bronchial Brush • Specimen Collection Container • CytoLyt Solution • Biohazard Safety Bag Specimen Collection: 1. Label specimen container with 2 patient identifiers 2. Collect specimen on brush. 3. Cut off brush end and immediately submerge brush in CytoLyt to avoid air-drying effects Specimen Handling: Room temperature if specimen is delivered upon collection*

*If delivery delay is unavoidable, refrigerate Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Cytology Specimen Requisition Transportation: Deliver/send to laboratory as soon as possible Comments / Special • Do not fix brush in formalin or let dry. Instructions: • Do not fix slides in formalin or let dry • CytoLyt solution can be obtained from Cytology at HMC or the Pathology Gross Room at UWMC Rejection Criteria: • Inadequate Information/missing requisition • Unlabeled/mislabeled specimen • Specimen received in inappropriate fixative. Do not use formalin as a fixative. Retention Time of Specimen: One (1) Week After Final Report is Issued Laboratory Subsection: Cytopathology – Harborview **Turnaround times vary depending on multiple specimen and laboratory factors.

3-3 3.4 Bronchial Washing

Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Turnaround Time**: 5 business days Specimen Collection Supplies: • Specimen Collection Container • Biohazard Safety Bag Specimen Specimen Collection: During a bronchoscopy, washings are obtained after the insertion of about 10 ml of physiological saline. This is instilled in small portions of 2-3ml at a time and collected in a tube connected as a trap in the vacuum line, via the bronchoscope while the patient coughs. The flexible tip of the scope may be directed towards the opening of the smaller bronchioles and several areas sampled. Additional material may be obtained by rinsing the bronchoscope after withdrawal. In order to localize the lesion, separate bronchoscopes must be used for each lobe in question.

The diluted lavage or wash is sent immediately to the lab for processing, in the capped collection tube. Specimen Handling: Room temperature if specimen is delivered upon collection* (up to four [4] hours)

*If delivery delay is anticipated, refrigerate to prevent bacterial growth. *If delay is longer than overnight, add equal amount of CytoLyt or 50% ethanol for proper fixation. Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Cytology Specimen Requisition Transportation: Deliver/send to laboratory as soon as possible Comments / Special • If specimen is too large for an equal volume of fixative in the Instructions: collection tube, divide in between two containers and add an equal volume of CytoLyt or 50% ethanol to each Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Specimen received in inappropriate fixative Retention Time of Specimen: One (1) Week After Final Report is Issued Contact Information: Cytopathology - Harborview **Turnaround times vary depending on multiple specimen and laboratory factors.

3-4 3.5 Cerebrospinal Fluid (CSF)

Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Turnaround Time**: 5 business days Specimen Collection Supplies: • Specimen Collection Container • Biohazard Safety Bag

If delay is anticipated to be longer than 24 hours for delivery: • CytoLyt solution Specimen Collection: 1. Discard the first drops from the tap. 2. Obtain as much spinal fluid as clinical judgment allows. 3. Place a screw-top tube supplied by the floor. Prioritize the necessary lab tests, i.e. microbiology, hematology, cytology. Specimen Handling: Room temperature if specimen is delivered upon collection.*

*If slight delivery delay is anticipated, refrigerate

*If a longer delivery delay is anticipated (more than 24hours), record the volume of the specimen and deposit the specimen in CytoLyt solution. Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Cytology Specimen Requisition Transportation: Immediately deliver/send to laboratory Comments / Special CSF is a highly perishable specimen; if specimen is to be obtained in Instructions: the afternoon notify the laboratory.

CytoLyt solution can be obtained from Cytology at HMC or the Pathology Gross Room at UWMC

For Lymphoma/Leukemia send directly to Hematopathology in SCCA (206-288-7060)

Do not fix in formalin Rejection Criteria: • Inadequate Information/missing requisition • Unlabeled/mislabeled specimen • Specimen received in inappropriate fixative • CSF that has been frozen or spun Retention Time of Specimen: One (1) Week After Final Report is Issued Laboratory Subsection: Cytopathology - Harborview **Turnaround times vary depending on multiple specimen and laboratory factors.

3-5 3.6 Fine Needle Aspiration (FNA) Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Turnaround Time**: 5 business days Specimen Collection Supplies: • Slides • Pap fixative (95% Ethanol) • Needle • Syringe • Physiological Saline • Biohazard Safety Bag If Delayed: • 50% Ethanol or, • CytoLyt Solution Specimen Collection: 1. Label slides with at least 2 patient identifiers 2. Express one drop of aspirated material on a labeled slide. The needle tip should be brought close to the slide with the beveled edge of the tip facing down towards the slide. 3. Touch the drop of material with another clean labeled slide and apply gentle pressure to procedure a monolayer of cells on both slides. 4. Immediately drop the two slides back to back into pap fixative (95% ethanol). 5. Rinse the needle by drawing saline into the syringe and expel back into the saline container.

If slides and pap fixative are not available, deposit and rinse the entire sample in CytoLyt solution Specimen Handling: Room temperature if specimen is delivered upon collection.*

*Refrigerate if delay is anticipated *If more than a 24 hour delay is anticipated, express the sample into CytoLyt solution. Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Cytology Specimen Requisition Transportation: Immediately deliver/send to laboratory Comments / Special To request a fine needle aspirate (performed by a Cytopathologist) Instructions: call Harborview Pathology to schedule assistance.

CytoLyt solution can be obtained from Cytology at HMC or the Pathology Gross Room at UWMC

Do not fix in formalin Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Specimen received in inappropriate fixative Retention Time of Specimen: One (1) Week After Final Report is Issued Laboratory Subsection: Cytopathology - Harborview **Turnaround times vary depending on multiple specimen and laboratory factors. 3-6 3.7 Miscellaneous Aspiration (Cysts, Joints, Etc)

Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Turnaround Time**: 5 business days Specimen Collection Supplies: • Needles • Syringe • Specimen Collection Container • CytoLyt Solution • Biohazard Safety Bag Specimen Collection: 1. Collect fluid in syringe. 2. Transfer fluid into a clean labeled container. Or remove the needle, cap off the syringe and submit the specimen in the syringe. 3. Label the syringe or container with patient identifiers.

For small volume of fluids (less than 5ml) and/or if delivery delay is anticipated, deposit the fluid in CytoLyt solution. Specimen Handling: • Fresh unfixed specimen • Room temperature if specimen is delivered upon collection.*

*Refrigerate if delay is anticipated *If delivery is delayed by more than 24 hours, deposit in CytoLyt solution. Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Cytology Specimen Requisition Transportation: Immediately deliver/send to laboratory Comments / Special Do not use formalin as a fixative Instructions: CytoLyt solution can be obtained from Cytology at HMC or the Pathology Gross Room at UWMC Rejection Criteria: • Inadequate Information/missing requisition • Unlabeled/mislabeled specimen • Specimen received in inappropriate fixative Retention Time of Specimen: One (1) Week After Final Report is Issued Laboratory Subsection: Cytopathology - Harborview **Turnaround times vary depending on multiple specimen and laboratory factors

3-7 3.8 Miscellaneous Brushing (Renal, Gastric, Common Bile Duct, Endocervical Cytobrush, Etc)

Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Turnaround Time**: 5 business days Specimen Collection Supplies: • Brush • CytoLyt Solution • Specimen Container • Biohazard Safety Bag Specimen Collection: 1. Obtain specimen on brush by brushing lesion. For endocervical brushings, the cytobrush is passed into the endocervical canal and rotated 360° five times. 2. Cut off brush end and place in CytoLyt solution immediately. Specimen Handling: Room temperature if specimen is delivered upon collection. Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Cytology Specimen Requisition Transportation: Immediately deliver/send to laboratory Comments / Special Do not fix specimen in formalin or let dry. Instructions: CytoLyt Solution can be obtained from Cytology at Harborview or UWMC Pathology Gross Room Rejection Criteria: • Inadequate Information/missing requisition • Unlabeled/mislabeled Specimen • Specimen received in inappropriate fixative Retention Time of Specimen: One (1) Week After Final Report is Issued Laboratory Subsection: Cytopathology - Harborview **Turnaround times vary depending on multiple specimen and laboratory factors

3-8 3.9 Sputum

Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Turnaround Time**: 5 business days Specimen Collection Supplies: • Specimen Collection Container • Biohazard Safety Ba Specimen Collection: Early morning spontaneous deep cough technique is appropriate for symptomatic patients with pulmonary disease and free airways. The patient should be given three, wide mouth, disposable, labeled containers and instructed as follows:

1. For three successive mornings, upon waking, clear throat of any material that accumulated overnight and discard. 2. Rinse mouth out with water several times. 3. Cough deeply several times during the waking hour each morning. 4. Spit whatever rises with the coughs into the specimen collection cup, using different cups each morning. 5. Refrigerate containers until delivered to laboratory. Specimen Handling: Refrigerated Specimen Requirements: • Labeled with two (2) patient identifiers • Completed cytology specimen requisition Transportation: Deliver/send to laboratory as soon as possible Comments / Special Three consecutive early morning specimen's increase they yield of Instructions: malignant cells.

Do not use formalin as a fixative Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Specimen received in inappropriate fixative Retention Time of Specimen: One (1) Week After Final Report is Issued Laboratory Subsection: Cytopathology - Harborview **Turnaround times vary depending on multiple specimen and laboratory factors

3-9 3.10 Sputum for PCP

Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Turnaround Time**: 5 business days Specimen Collection Supplies: • Specimen Collection Container • Biohazard Safety Bag Specimen Collection: Collect fresh unfixed induced specimen. Specimen Handling: Refrigerated Specimen Requirements: • Labeled with two (2) patient identifiers • Completed cytology specimen requisition, include r/o PCP request Transportation: Deliver/send to laboratory as soon as possible Comments / Special Sputum induction is intended primarily for the detection of early Instructions: lung carcinoma in asymptomatic persons who have too little sputum to be raised naturally. It is also used for the detection of PCP.

Non-induced specimen will not be processed for PCP.

Do not use formalin as a fixative Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Specimen received in inappropriate fixative • Non-induced specimen Retention Time of Specimen: One (1) Week After Final Report is Issued Laboratory Subsection: Cytopathology - Harborview **Turnaround times varies depending on multiple specimen and laboratory factors

3-10 3.11 Thyroid Aspirate

Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Turnaround Time**: 5 business days Specimen Collection Supplies: • Slides • Pap Fixative (95% ETOH) • CytoLyt Fixative • Biohazard Safety Bag Specimen Collection: 1. Label each slide with patient's name. 2. Once aspiration is obtained, express one drop of aspirated material on a labeled slide with the beveled edge on tip facing down towards the slide. 3. Touch the drop of material with another clean labeled slide and apply gentle pressure to procedure a monolayer of cells on both slides. 4. Immediately drop the two slides back to back into pap fixative (95% ethanol). 5. Rinse the needle by drawing CytoLyt or saline solution into the syringe and expel back into the vial for each pass.

If slides and pap fixative are not available, deposit and rinse the entire sample of CytoLyt or saline solution. Specimen Handling: Room temperature if specimen is delivered upon collection Specimen Requirements: • Labeled with two (2) patient identifiers • Completed cytology specimen requisition Transportation: Deliver/send to laboratory as soon as possible

Comments / Special CytoLyt can be obtained from Cytology at HMC or the Instructions: Gross Room at UWMC

3-11 3.12 Urine – Voided

Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Turnaround Time**: 5 business days Specimen Collection Supplies: • Specimen Collection Container • Biohazard Safety Bag

If long delay is anticipated for delivery: • CytoLyt or 50% Ethanol Specimen Collection: Optimum volume is 100ml. 50-100ml is adequate. Specimen Handling: Room temperature if specimen is delivered upon collection*

*If overnight or weekend delay is anticipated, refrigerate *If a longer delivery delay is unavoidable, add equal volume of CytoLyt or 50% ethanol Specimen Requirements: • Labeled with two (2) patient identifiers • Completed cytology specimen requisition Transportation: Deliver/send to laboratory as soon as possible Comments / Special Optimal sample should be obtained after hydration and exercise. Instructions: Clean-catch, midstream urine is recommended.

Pooled 24 hour and/or concentrated early morning specimens are not recommended due to an increased chance of cellular deterioration and accumulation of salts Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Specimen received in inappropriate fixative. Do not use formalin as a fixative. • First morning urine specimens Retention Time of Specimen: One (1) Week After Final Report is Issued Laboratory Subsection: Cytopathology - Harborview **Turnaround times varies depending on multiple specimen and laboratory factors

3-12 3.13 Urine – Catheterized

Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Turnaround Time**: 5 business days Specimen Collection Supplies: • Specimen Collection Container • Biohazard Safety Bag

*If overnight or weekend delay is anticipated, refrigerate *If a longer delivery delay is unavoidable, add equal volume of CytoLyt or 50% ethanol Specimen Requirements: • Labeled with two (2) patient identifiers • Completed cytology specimen requisition Transportation: Deliver/send to laboratory as soon as possible Comments / Special Catheterized urine is preferred for the lack of contamination and Instructions: greater content of transitional cells.

If there are questions of low-grade transitional carcinoma, prior to insertion of catheter, it is helpful to collect voided baseline urine for comparison to the catheterized specimen.

Excessive lubricant should be avoided as it may obscure the cells.

Do not send first morning urine. Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Specimen received in inappropriate fixative. Do not use formalin as a fixative. • First morning urine specimens Retention Time of Specimen: One (1) Week After Final Report is Issued Laboratory Subsection: Cytopathology - Harborview **Turnaround times varies depending on multiple specimen and laboratory factors

3-13 Molecular Diagnostics Services

4.1 Human Papilloma Virus (GYN in ThinPrep Pap Test Media)

Day(s) / Time (s) Performed: Variable Depending on Workload Tests Run 2-3 Times per Week Turnaround Time**: Four (4) Business Days Specimen Collection Supplies: • ThinPrep Pap Test (PreservCyt) Vial (Not CytoLyt) • Plastic Spatula • Endocervical brush • Biohazard Safety Bag • Requisition Specimen Collection: 1. Label vial with two patient identifiers. 2. Obtain adequate sample from endocervix and endocervical canal using plastic spatula and endocervical brush. 3. Rinse vigorously 10 times in solution to remove any residual sample from spatula and brush. 4. Tighten cap and place vial and requisition in bag for transport to laboratory Specimen Handling: Room Temperature Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Molecular Specimen Requisition Transportation: Deliver/send to laboratory as soon as possible Comments / Special • Ordered as Co-Test, Reflexive to Pap results or Instructions: • HPV with Reflexive Pap (Primary HPV) • HPV Screen with Genotype1 (16, 18, and Other 12 High Risk types) Rejection Criteria: • Incorrect information/missing requisition • Unlabeled/mislabeled specimen • Incorrect or expired collection media Retention Time of Specimen: Three (3) Months Laboratory Subsection: Molecular Diagnostic - Harborview 1. In concordance with HPV Genotyping Clinical Update, 2009, reported by American Society of Colposcopy and Cervical Pathology **Turnaround times vary depending on multiple specimen and laboratory factors.

4-1 4.1.1 GYN in SurePath Media

Day(s) / Time (s) Performed: Variable depending on Workload Tests run 2-3 times per week Turnaround Time**: Four (4) business days Specimen Collection Supplies: • SurePathTM preservative vial • Broom Collection Device with Detachable Head • Combination Cytobrush/plastic Spatula with detachable heads • Biohazard Safety Bag Specimen Collection: 1. Label SurePathTM preservative vial with a minimum of patient's name and birthdate or requisition label 2. Include all pertinent clinical information (LMP, hormone use, Pap and biopsy history, etc) on the test requisition 3. Prior to specimen collection, clean away visible blood, mucus and/or discharge from cervix. 4. A. Insert broom device into endocervical canal and rotate 5 times clockwise. Detach head of broom and place in vial. 4 B. Insert contoured end of plastic spatula into endocervical canal and rotate 360 degrees. Detach head and place in vial. Insert Cytobrush into endocervical canal and slowly rotate 1/4 to 1/2 turn in one direction. Detach head and place in vial Specimen Handling: Room Temperature Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Molecular Specimen Requisition Transportation: Deliver/send to laboratory as soon as possible Comments / Special HPV Screen with Genotype 1 (16, 18, and Other 12 High Risk types) Instructions: Rejection Criteria: • Inadequate Information/missing requisition • Unlabeled/mislabeled specimen • Incorrect or expired collection media Retention Time of Specimen: Three (3) Month Laboratory Subsection: Molecular Diagnostic - Harborview 1. In concordance with HPV Genotyping Clinical Update, 2009, reported by American Society of Colposcopy and Cervical Pathology **Turnaround times vary depending on multiple specimen and laboratory factors.

4-2 4.1.2 GYN in Qiagen Specimen Transport Media (STM)

Day(s) / Time (s) Performed: Variable depending on Workload Tests run 2-3 times per week Turnaround Time**: Four (4) business days Specimen Collection Supplies: • Qiagen STM collection kit (Tube with 1ml STM and pre-scored Dacron Swab) • Optional: Cytobrush • Biohazard Safety Bag Specimen Collection: 1. Label Qiagen STM tube with a minimum of patient's name and date of birth or requisition label. 2. Include all pertinent clinical information (LMP, hormone use, Pap and biopsy history, etc) on the test requisition 3. Prior to specimen collection, clean away visible blood, mucus and/or discharge from cervix. 4. A. Insert Cytobrush into endocervical canal and rotate 3 times. Place brush in STM tube and break off shaft of brush. 4 B. Insert Dacron Swab into endocervical canal and rotate in alternating directions 5 times. Place brush in STM tube and break off shaft of brush Specimen Handling: Room Temperature

Note: Can be stored at room temperature for up to two (2) weeks. After two weeks, needs to be stored at 2-8oC Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Molecular Specimen Requisition Transportation: Deliver/send to laboratory as soon as possible Comments / Special HPV Screen with Genotype 1 (16, 18, and Other 12 High Risk types) Instructions: Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Incorrect or expired collection media Retention Time of Specimen: Three (3) Months Laboratory Subsection: Molecular Diagnostic - Harborview 1. In concordance with HPV Genotyping Clinical Update, 2009, reported by American Society of Colposcopy and Cervical Pathology **Turnaround times vary depending on multiple specimen and laboratory factors.

4-3 4.1.3 Anal in Qiagen Specimen Transport Media (STM)

Day(s) / Time (s) Performed: Variable depending on Workload Tests run 2-3 times per week Turnaround Time **: Four (4) business days Specimen Collection Supplies: • Qiagen STM collection kit (Tube with 1ml STM and pre- scored Dacron Swab) • Optional: Cytobrush • Biohazard Safety Bag Specimen Collection: 1. Label Qiagen STM tube with a minimum of patient's name and date of birth or requisition label. 2. Include all pertinent clinical information (LMP, hormone use, Pap and biopsy history, etc) on the test requisition 3. Prior to specimen collection, clean away visible blood, mucus and/or discharge from area of interest. 4. A. Insert Cytobrush into area of interest and rotate 3 times. Place brush in STM tube and break off shaft of brush. 4 B. Insert Dacron Swab into area of interest and rotate in alternating directions 5 times. Place brush in STM tube and break off shaft of brush Specimen Handling: Room Temperature

Note: Can be stored at room temperature for up to two (2) weeks. After two weeks, needs to be stored at 2-8oC Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Molecular Specimen Requisition Transportation: Deliver/send to laboratory as soon as possible Comments / Special HPV Screen with Genotype1 (16, 18, and Other 12 High Risk types) Instructions: Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Incorrect or expired collection media Retention Time of Specimen: Three (3) Months Laboratory Subsection: Molecular Diagnostic - Harborview 1. In concordance with HPV Genotyping Clinical Update, 2009, reported by American Society of Colposcopy and Cervical Pathology **Turnaround times vary depending on multiple specimen and laboratory factors.

4-4 4.1.4 Anal in ThinPrep Media

Day(s) / Time (s) Performed: Variable Depending on Workload Tests Run 2-3 Times per Week Turnaround Time **: Four (4) Business Days Specimen Collection Supplies: • ThinPrep Pap Test (PreservCyt) Vial (Not CytoLyt) • Plastic Spatula • Endocervical brush • Biohazard Safety Bag • Requisition Specimen Collection: 1. Label ThinPrep vial with a minimum of patient's name and date of birth or requisition label. 2. Include all pertinent clinical information (LMP, hormone use, Pap and biopsy history, etc.) on the test requisition 3. Prior to specimen collection, clean away visible blood, mucus and/or discharge from area of interest. 4. A. Insert Cytobrush into area of interest and rotate 3 times. Place brush in ThinPrep vial and break off shaft of brush. 5. B. Insert Dacron Swab into area of interest and rotate in alternating directions 5 times. Place brush in ThinPrep vial and break off shaft of brush Specimen Handling: Room Temperature Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Molecular Specimen Requisition Transportation: Deliver/send to laboratory as soon as possible Comments / Special Ordered as Co-Test or Reflexive to Pap results. HPV Screen with Instructions: Genotype1 (16, 18 and Other 12 High Risk types) Rejection Criteria: • Incorrect information/missing requisition • Unlabeled/mislabeled specimen • Incorrect or expired collection media Retention Time of Specimen: Three (3) Months Laboratory Subsection: Molecular Diagnostic – Harborview 1. In concordance with HPV Genotyping Clinical Update, 2009, reported by American Society of Colposcopy and Cervical Pathology **Turnaround times vary depending on multiple specimen and laboratory factors.

4-5 Histology Services 5.1 Frozen Sections UWMC-MT Day(s) / Time (s) Performed: Monday – Sunday 24/7 : Regular business hours 8am – 5pm Turnaround Time **: Single Requests - 20 minutes Multiple/Weekend/Off-Hour Requests – Variable Specimen Collection Supplies: • Biohazard Safety Bag/sterile container Specimen Collection: Fresh Tissue Specimen Handling: • Room temperature • Sent STAT • Call/Page appropriately o Provide OR# and Surgeons name requesting frozen o Include whether a Pathologist needs review or if a regular courier pick-up is required CALL 206/598-0330 to request an intraoperative consultation from 8am – 5pm Page the on-call pathology resident to request an intraoperative consultation from 5pm – 8am the following day. Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Surgical Specimen Requisition • Fresh Tissue Transportation: Surgical Pavilion: HA Immediate Delivery Main OR: Pathology resident pick-up after notification by OR Comments / Special For proper specimen management, specimens must be fresh and Instructions: sent immediately. Frozen section requests are NOT to be used as a courier service without intraoperative consultation work. Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Specimen submitted in Formalin Retention Time of Specimen: Two (2) Weeks After Final Report is Issued Laboratory Subsection: Gross Room / Histology - UWMC-MT **Turnaround times varies depending on multiple specimen and laboratory factors

5-1 5.2 Frozen Sections UWMC-NW Day(s) / Time (s) Performed: Monday – Sunday 24/7 : Regular business hours 8:30am – 5pm Turnaround Time **: Single Requests - 20 minutes Multiple/Weekend/Off-Hour Requests – Variable

Specimen Collection Supplies: • Biohazard Safety Bag / Sterile Container

Specimen Collection: Fresh Tissue

Specimen Handling: • Room temperature • Sent STAT • Call/Page appropriately o Provide OR# and Surgeons name requesting frozen CALL the OPERATOR 206/668-4556 to page the daytime/afterhours on-call Pathologist for an intraoperative consultation from 8am – 5pm Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Surgical Specimen Requisition • Fresh Tissue

Transportation: Surgical Pavilion: HA Immediate Delivery Main OR: Pathology resident pick-up after notification by OR

Comments / Special For proper specimen management, specimens must be fresh and Instructions sent immediately. Frozen section requests are NOT to be used as a courier service without intraoperative consultation work. Rejection Criteria: • Inadequate information / missing requisition • Unlabeled / Mislabeled Specimen • Specimen Submitted in Formalin

Retention Time of Specimen: Two (2) Weeks After Final Report is Issued

Laboratory Testing Performed: Gross Room / Histology - UWMC-NW

**Turnaround times varies depending on multiple specimen and laboratory factors

5-2 5.3 Frozen Sections HMC Day(s) / Time (s) Performed: Monday – Sunday 24/7 : Regular business hours 8:30am – 5pm Turnaround Time **: Single Requests - 20 minutes Multiple/Weekend/Off-Hour Requests – Variable

Specimen Collection Supplies: • Biohazard Safety Bag / Sterile Container

Specimen Collection: Fresh Tissue

Specimen Handling: • Room temperature • Sent STAT • Call/Page appropriately o Provide OR# and Surgeons name requesting frozen o Include whether a Pathologist needs review or if a regular courier pick-up is required. CALL 206/744-3145 to request an intraoperative consultation from 8:30am – 4:50pm CALL the OPERATOR 206/744-3000 afterhours from 4:50pm – 8:29am the following day and request the on-call Pathologist. Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Surgical Specimen Requisition • Fresh Tissue

Transportation: During regular business hours a Pathology technician will pick-up the frozen specimen from the specific OR requesting one. After-hours the on-call Pathologist will pick the frozen specimen up from the main OR desk.

Retention Time of Specimen: Two (2) Weeks After Final Report is Issued

Laboratory Testing Performed: Gross Room / Histology - HMC

**Turnaround times varies depending on multiple specimen and laboratory factors

5-3

5.4 Gross Examination

Day(s) / Time (s) Performed: Monday – Sunday 24/7 : Regular business hours 8:30am – 5pm Turnaround Time **: Single Requests - 20 minutes Multiple/Weekend/Off-Hour Requests – Variable Specimen Collection Supplies: • Biohazard Safety Bag / Sterile Container Specimen Collection: Fresh Tissue Specimen Handling: • Room temperature • Sent STAT • Call/Page appropriately o Provide OR# and Surgeons name requesting frozen CALL the OPERATOR 206/668-4556 to page the daytime/afterhours on-call Pathologist for an intraoperative consultation from 8am – 5pm Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Surgical Specimen Requisition • Fresh Tissue Transportation: Surgical Pavilion: HA Immediate Delivery Main OR: Pathology resident pick-up after notification by OR Comments / Special For proper specimen management, specimens must be fresh and Instructions: sent immediately. Frozen section requests are NOT to be used as a courier service without intraoperative consultation work. Rejection Criteria: • Inadequate information / missing requisition • Unlabeled / Mislabeled Specimen • Specimen Submitted in Formalin Retention Time of Specimen: Two (2) Weeks After Final Report is Issued Laboratory Subsection: Gross Room / Histology - UWMC-NW **Turnaround times varies depending on multiple specimen and laboratory factors

5-4 5.5 Bone Marrow Biopsy Specimens

Day(s) / Time (s) Performed: Monday – Sunday 24/7 : Regular business hours 8:30am – 5pm Turnaround Time **: Single Requests - 20 minutes Multiple/Weekend/Off-Hour Requests – Variable Specimen Collection Supplies: • Biohazard Safety Bag / Sterile Container Specimen Collection: Fresh Tissue Specimen Handling: • Room temperature • Sent STAT • Call/Page appropriately o Provide OR# and Surgeons name requesting frozen o Include whether a Pathologist needs review or if a regular courier pick-up is required. CALL 206/744-3145 to request an intraoperative consultation from 8:30am – 5pm CALL the OPERATOR 206/744-3000 afterhours from 5pm – 8am the following day and request the on-call Pathologist. Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Surgical Specimen Requisition • Fresh Tissue Transportation: During regular business hours a Pathology technician will pick-up the frozen specimen from the specific OR requesting one. After-hours the on-call Pathologist will pick the frozen specimen up from the main OR desk. Comments / Special For proper specimen management, specimens must be fresh and Instructions: sent immediately. Frozen section requests are NOT to be used as a courier service without intraoperative consultation work. Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/Mislabeled Specimen • Specimen Submitted in Formalin Retention Time of Specimen: Two (2) Weeks After Final Report is Issued Laboratory Subsection: Gross Room / Histology - HMC **Turnaround times varies depending on multiple specimen and laboratory factors

5-5 5.6 Renal Biopsy Specimens

Day(s) / Time (s) Performed: Monday – Friday 8am - 5pm Turnaround Time: 6 business days Specimen Collection Supplies: • EM Fixative • Michel's IF Media • Formalin • At HMC, all the above fixatives can be obtained as a kit from HMC Gross Room refrigerator (2NJ274). • Biohazard Safety Bag Specimen Collection: • Tissue Core Biopsies Specimen Handling: Room temperature Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Surgical Specimen Requisition Transportation: As soon as possible deliver/send to Gross Room Refrigerator. Deliver to NW211 Monday-Friday if STAT. Comments / Special Fixatives can be obtained from HMC Gross room refrigerator Instructions: (2NJ274) or UWMC Gross Room refrigerator (NW211B). Access code required. • For UWMC-Renal kit/Fixative is available in NW211. • For HMC-Renal kit is available in 2NJ274 Gross room fridge. • For facilities outside of UWMC system- renal kits are shipped upon request. Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Specimen submitted in preservative other than the preferred preservative for required testing method. Retention Time of Specimen: Two (2) weeks after final report is issued. Laboratory Subsection: Gross Room/Histology-UWMC **Turnaround times varies depending on multiple specimen and laboratory factors

5-6 5.7 Surgical Tissue Specimens

Day(s) / Time (s) Performed: Monday – Friday 8:00 am - 5:00 pm Turnaround Time **: 24 - 72 Hour Specimen Collection Supplies: • 10% Neutral Buffered Formalin (NBF) - if fixation is necessary • Sterile Specimen Collection Container - if appropriate for size • Biohazard Safety Bag Specimen Collection: • As deemed appropriate by physician/surgeon Specimen Handling: • Room temperature if delivered immediately or fixed in10% Neutral Buffered Formalin • Refrigerated if delayed delivery is anticipated and specimen is fresh Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Surgical Specimen Requisition Transportation: As soon as possible deliver/send to Gross Room Refrigerator or Pathology Specimen Refrigerator, as applicable Comments / Special For proper specimen management, specimens should be received Instructions: in pathology as soon as possible Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Specimen submitted in preservative other than the preferred preservative for required testing method. Retention Time of Specimen: Two (2) Weeks After Final Report is Issued Laboratory Subsection: Gross Room/Histology – Harborview, UWMC-MT, and UWMC-NW **Turnaround times varies depending on multiple specimen and laboratory factors

5-7 5.8 Tissue Biopsy Specimens

Day(s) / Time (s) Performed: Monday – Friday 8:00 am - 5:00 pm Turnaround Time**: 24 - 72 Hours Specimen Collection Supplies: • 10% Neutral Buffered Formalin—unless special testing is requested (i.e., flow cytometry) • Biohazard Safety Bag Specimen Collection: • As deemed appropriate by physician/surgeon Specimen Handling: • Room temperature - if sent to pathology as soon as possible or fixed in 10% Neutral Buffered Formalin • Refrigerated - if submitted fresh and delay is anticipated. Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Surgical Specimen Requisition Transportation: As soon as possible deliver/send to Gross Room Refrigerator or Pathology specimen refrigerator, as applicable Comments / Special For proper specimen management, fresh tissue specimens should Instructions: be received in pathology as soon as possible. Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Specimen submitted in preservative other than the preferred preservative for required testing method. Retention Time of Specimen: Two (2) Weeks After Final Report is Issued Laboratory Subsection: Gross Room/Histology – Harborview, UWMC-MT, UWMC-NW **Turnaround times varies depending on multiple specimen and laboratory factors

5-8 Neuropathology Services 6.1 Brain/Spine Biopsy Specimens

Day(s) / Time (s) Performed: Monday – Friday 8:00 am - 5:00 pm Turnaround Time**: 48 - 120 hours Specimen Collection Supplies: • 10% Neutral Buffered Formalin—unless special testing is requested (i.e., flow cytometry) • Biohazard Safety Bag Specimen Collection: • As deemed appropriate by surgeon Specimen Handling: • Room temperature - if sent to pathology as soon as possible • Refrigerated - if delay is anticipated Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Surgical Specimen Requisition Transportation: Immediately deliver to Gross Room Refrigerator at UWMC-MT (EC239), UWMC-NW (A265), or HMC (2NJ274) Comments / Special For proper specimen management, fresh tissue specimens should Instructions: be received in pathology as soon as possible. Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen Retention Time of Specimen: Two (2) Weeks After Final Report is Issued Laboratory Subsection: Gross Room/Histology – Harborview **Turnaround times varies depending on multiple specimen and laboratory factors

6-1 6.2 Brain Tumor Specimen for Fluorescent In Situ Hybridization (FISH)

Day(s) / Time (s) Performed: Mondays and Thursdays 8:00 am - 5:00 pm Turnaround Time**: 10 Business Days Specimen Collection Supplies: • Sterile Specimen Collection Container • Biohazard Safety Bag Specimen Collection: • As deemed appropriate by surgeon Specimen Handling: • Room temperature - if sent to pathology as soon as possible • Refrigerated - if delay is anticipated Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Molecular Specimen Requisition Transportation: Immediately deliver to Gross Room Refrigerator at UWMC-MT, UWMC-NW, or HMC Comments / Special For proper specimen management, fresh tissue specimens should Instructions: be received in pathology as soon as possible. Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen Retention Time of Specimen: Two (2) Weeks After Final Report is Issued Laboratory Subsection: Molecular Diagnostic Laboratory – Harborview **Turnaround times varies depending on multiple specimen and laboratory factors

6-2 6.3 Muscle Specimens

Day(s) / Time (s) Performed: Monday – Friday 8:00 am - 5:00pm Turnaround Time**: 10 Business Days Specimen Collection Supplies: • Tongue Blade or Stiff Paper • Saline • Telfa or Gauze • Sterile Specimen Container/Petri Dish • Biohazard Safety Bag Wet Ice Specimen Collection: 1. Obtain a longitudinal muscle biopsy, 0.8 to 1.0 cm in diameter and at least 3 cm in length. If the initial sample is too small, additional sample should be taken. 2. Place the specimen on a tongue blade or stiff paper and cover the muscle with Telfa or gauze moistened with saline. 3. Place the specimen in a container (Petri dish or Specimen Jar) with wet ice and place in a biohazard bag. Do not immerse the specimen in saline. Do not use muscle clamps unless surgeon requires their use. Specimen Handling: Room temperature. Refrigerate if not delivered immediately. Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Neuropathology Specimen Requisition Transportation: Immediately deliver to Gross Room at HMC (2NJ274), UWMC-MT (EC239), or UWMC-NW (A265) Comments / Special For proper specimen management, muscle biopsies should be Instructions: delivered immediately to the Gross Room. Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Muscle Immersed in Saline or improper fixative used. Retention Time of Specimen: Two (2) Weeks After Final Report is Issued Laboratory Subsection: Gross Room/Histology – Harborview **Turnaround times varies depending on multiple specimen and laboratory factors

6-3 6.4 Nerve Specimens

Do not immerse specimen in saline Specimen Handling: Room temperature. Refrigerate if not delivered immediately. Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Neuropathology Specimen Requisition Transportation: Immediately Deliver to Gross Room at HMC (2NJ274), UWMC-MT (EC239), or UWMC-NW (A265) Comments / Special For proper specimen management, nerve biopsies should be Instructions: delivered immediately to the gross room. Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Nerve immersed in saline or improper fixative used Retention Time of Specimen: Two (2) Weeks After Final Report is Issued Laboratory Subsection: Gross Room / Histology – Harborview **Turnaround times varies depending on multiple specimen and laboratory factors

6-4 6.5 Ocular Biopsy Specimens

Day(s) / Time (s) Performed: Monday – Friday 8:00 am - 5:00 pm Turnaround Time**: 2-5 Business Days (except Eye Globes) Specimen Collection Supplies: • 10% Neutral Buffered Formalin—unless special testing is requested (i.e., flow cytometry) • Biohazard Safety Bag Specimen Collection: • As deemed appropriate by surgeon Specimen Handling: Room temperature. Refrigerate if not delivered immediately. Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Neuropathology Specimen Requisition Transportation: Immediately deliver to gross room at HMC (2NJ274), UWMC-MT (EC239), or UWMC-NW (A265) Comments / Special For proper specimen management, ocular biopsies should be Instructions: delivered immediately to the gross room. Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled Specimen • Improper fixation method used Retention Time of Specimen: Two (2) weeks after Final Report is Issued Laboratory Subsection: Gross Room/Histology – Harborview **Turnaround times varies depending on multiple specimen and laboratory factors

6-5 Immunofluorescence 7.1 Direct Immunofluorescence 7.1.1 Oral Biopsy Specimens

Day(s) / Time (s) Performed: Monday – Friday 8:00 am 5:00 pm Turnaround Time**: 24-72 Hours Specimen Collection Supplies: • Biohazard Safety Bag • IF Transport Media ONLY Specimen Collection: • As deemed appropriate by surgeon • 4mm punch biopsy • 5mm punch biopsy, if biopsy is to be divided Specimen Handling: Room temperature Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Specimen Requisition Transportation: As soon as possible deliver/send to Pathology Comments / Special Immunofluorescence panel includes: IgG, IgA, IgM, C3 & Instructions: Fibrinogen.

IF Transport Media may be obtained from Gross Room refrigerator (NW211B) at UWMC. Access code required. Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled Specimen • Specimen submitted in preservative not preferred for required testing methodology • Specimen received in formalin • Specimen received in saline Retention Time of Specimen: 6 Months After Final Report is Issued - Specimen is Frozen Laboratory Subsection: Immunohistochemistry (IHC) – UWMC **Turnaround times varies depending on multiple specimen and laboratory factors

7-1 7.1.2 Skin Specimens

Day(s) / Time (s) Performed: Monday – Friday 8:00 am - 5:00 pm Turnaround Time**: 24-72 Hours Specimen Collection Supplies: • Sterile Specimen Collection Container • IF Transport Media • Michels • Biohazard Safety Bag Specimen Collection: • As deemed appropriate by surgeon • 4mm punch biopsy • 5mm punch biopsy, if biopsy is to be divided Specimen Handling: Room temperature Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Specimen Requisition Transportation: Deliver/send to pathology as soon as possible Comments / Special Immunofluorescence panel includes: IgG, IgA, IgM, C3 & Albumin, Instructions: C1q, H&E.

Include all relevant clinical history; e.g. sun exposure, involvement of specimen

IF Transport Media may be obtained from Gross Room refrigerator (NW211B) at UWMC. Access code required. Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled Specimen • Specimen submitted in preservative not preferred for required testing methodology • Specimen received in formalin Retention Time of Specimen: 6 months After Final Report is Issued - Specimen is Frozen Laboratory Subsection: Immunohistochemistry (IHC) – UWMC **Turnaround times varies depending on multiple specimen and laboratory factors

7-2 7.2 In-Direct Immunofluorescence 7.2.1 Serum Specimen

Day(s) / Time (s) Performed: Monday – Friday 8:00 am 5:00 pm Turnaround Time**: 24-72 Hours Specimen Collection Supplies: • Capped Test Tube / Vial • Red Top Tube for Peripheral Blood • Biohazard Safety Bag Specimen Collection: • 2 ml Serum (preferred) • 7 ml Peripheral Blood - use Red Top Tube for blood Specimen Handling: Refrigerated Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Specimen Requisition to include collection time. Differential Diagnosis request required. • Peripheral Blood must be received within 2 hours of blood draw • Notify lab ahead of sending specimen by calling 206-598-4028 or 206-598-6400 Transportation: As soon as possible deliver/send to Pathology BB220 Monday through Friday. Send on ice packets - do not freeze blood Comments / Special Serial dilution performed on serum applied different substrate Instructions: tissue dependent on the differential diagnosis • Centrifuge blood ASAP to separate serum Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Specimen submitted in preservative not preferred for required testing methodology • Blood is frozen Retention Time of Specimen: 6 months After Final Report is Issued Laboratory Subsection: Immunohistochemistry (IHC) - UWMC **Turnaround times varies depending on multiple specimen and laboratory factors

7-3 Cytogenetics Services 8.1 Amniotic Fluid

Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Saturday 8:00 am - 4:00 pm Sunday 10:00 am - 2:00 pm Turnaround Time**: • Chromosome Analysis: 7-14 days • Prenatal Aneuploidy FISH Panel: Preliminary 1-3 days • Prenatal Array CHG:10-14 days Specimen Collection Supplies: Corning tissue culture tubes or tubes from a Baxter Amniocentesis tray kit Biohazard Safety Bag Specimen Collection: Collect 15-30ml of fluid obtained under sterile conditions. Place the fluid into the Corning tissue culture tubes or tubes from the amniocentesis tray kit. Discard the first 1ml of fluid or use for AFP testing.

*For Array CGH: Collect 15-20ml of amniotic fluid or two T-25 flasks that are 90-100% confluent. Specimen Handling: Room Temperature Specimen Requirements: • Specimen container labeled with two (2) patient identifiers • Completed Cytogenetics Specimen Requisition Transportation: Deliver/send to laboratory as soon as possible Comments / Special n/a Instructions: Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Improper fixation of specimen Retention Time of Specimen: Two (2) weeks after Final Report is Issued Laboratory Subsection: Cytogenetics- UWMC **Turnaround times are averaged; some cases may be delayed due to slower than usual cell growth, incomplete paperwork, or other circumstances beyond the Cytogenetics Laboratory’s control.

8-1 8.2 Bone Marrow / Oncology Blood

Day(s) / Time (s) Performed: Monday - Friday 8:00 am 5:00 pm Saturday 8:00 am - 4:00 pm Sunday 10:00 am - 2:00 pm Turnaround Time**: • Chromosome Analysis: 5-10 days • STAT Chromosome Analysis: Preliminary 1-3 days Final 2-4 days • Neoplasia FISH Study: 2-5 days • Additional FISH Study: 1-3 days • STAT FISH Analysis Preliminary 24 hours/Final 1-3 days Specimen Collection Supplies: Preservative-Free Sodium Heparin Green Top Vacutainer or a Sterile Heparinized Syringe Biohazard Safety Bag Specimen Collection: Collect 3-5ml of bone marrow or 5-10ml of blood in a preservative- free sodium heparin (green top vacutainer) or in a sterile heparinized syringe. Specimen Handling: Room Temperature Specimen Requirements: • Specimen Container labeled with two (2) patient identifiers • Completed Cytogenetics Specimen Requisition Transportation: Deliver/send to laboratory as soon as possible Comments / Special n/a Instructions: Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled Specimen • Improper fixation of specimen Retention Time of Specimen: 2 Weeks After Final Report is Issued Laboratory Subsection: Cytogenetics – UWMC **Turnaround times are averaged; some cases may be delayed due to slower than usual cell growth, incomplete paperwork, or other circumstances beyond the Cytogenetics Laboratory’s control.

8-2 8.3 Chorionic Villi

Day(s) / Time (s) Performed: Monday - Thursday 8:00 am - 5:00 pm Turnaround Time**: • Chromosome Analysis: 7-14 days • Prenatal Aneuploidy FISH Panel: Preliminary 1-3 days • Prenatal Array CGH: 10-14 days Specimen Collection Supplies: Sterile Flask or tube with sterile tissue culture media Biohazard Safety Bag Specimen Collection: Collect 15-50mg chorionic villi in a sterile flask or tube with sterile tissue culture media.

*For Array CGH: Collect two T-25 flasks that are 90% to 100% confluent Specimen Handling: Room Temperature Specimen Requirements: • Specimen Container labeled with two (2) patient identifiers • Completed Cytogenetics Specimen Requisition Transportation: Deliver/send to laboratory as soon as possible Comments / Special n/a Instructions: Rejection Criteria: • Inadequate Information/missing requisition • Unlabeled/mislabeled specimen • Improper fixation of specimen Retention Time of Specimen: Two (2) Weeks After Final Report is Issued Laboratory Subsection: Cytogenetics – UWMC **Turnaround times are averaged; some cases may be delayed due to closer than usual cell growth, incomplete paperwork, or other circumstances beyond the Cytogenetics Laboratory’s control.

8-3 8.4 DNA Samples

Day(s) / Time (s) Performed: Monday – Friday 8:00 am - 5:00 pm Saturday 8:00 am - 4:00 pm Sunday 10:00 am - 2:00 pm Turnaround Time**: • Prenatal Array CGH:10-14 days • Routine Array CGH:14-21 days Specimen Collection Supplies: TE-Buffer Biohazard Bag Specimen Collection: Obtain 20-30mg of DNA suspended in TE-buffer Specimen Handling: Room Temperature Specimen Requirements: • Specimen Container labeled with two (2) patient identifiers • Completed Cytogenetics Specimen Requisition Transportation: Deliver/send to laboratory as soon as possible Comments / Special n/a Instructions: Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Improper fixation of specimen Retention Time of Specimen: Indefinitely Laboratory Subsection: Cytogenetics – UWMC **Turnaround times are averaged; some cases may be delayed due to slower than usual cell growth, incomplete paperwork, or other circumstances beyond the Cytogenetics Laboratory’s control.

8-4 8.5 Peripheral Blood

Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Saturday 8:00 am - 4:00 pm Sunday 10:00 am - 2:00 pm Turnaround Time**: • Routine Chromosome Analysis: 10-14 days • Metaphase FISH Study: 7-10 days • Mosaicism Study:14 days • Family Chromosome Follow-up Study: 3-14 days • Newborn Chromosome Study: Preliminary 2-3 days / Final 2-7 days • STAT FISH to rule out Aneuploidy: Preliminary 1-3 days / Final 1-3 days • Routine Array – CGH: 14-21 days Specimen Collection Supplies: Adult: Preservative-free sodium heparin Green Top Vacutainer Infants: Preservative-free sodium heparin Green Top Vacutainer or Sterile Heparinized Syringe Array CGH: 1 EDTA Purple Top Vacutainer and 1 Preservative-free sodium heparin Green Top Vacutainer Y-PCR for Male Infertility: EDTA Purple top Vacutainer Biohazard Safety Bag Specimen Collection: Adults: 5-10ml whole blood preservative-free sodium heparin Infants: 1-3ml whole blood preservative-free sodium heparin Array CGH: (2 tubes of blood REQUIRED) 3-5ml whole blood in EDTA and 3-5ml whole blood in sodium heparin Y-PCR for Male Infertility: 5ml whole blood in EDTA Specimen Handling: Room Temperature Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Cytogenetics Specimen Requisition Transportation: Deliver/send as soon as possible to laboratory Comments / Special n/a Instructions: Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Improper fixation of specimen Retention Time of Specimen: 2 Weeks After Final Report is Issued Laboratory Subsection: Cytogenetics – UWMC **Turnaround times are averaged; some cases may be delayed due to closer than usual cell growth, incomplete paperwork, or other circumstances beyond the Cytogenetics Laboratory’s control.

8-5 8.6 Solid Tissue (including Products of Conception, Skin Biopsies, Stillbirths)

Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Saturday 8:00 am - 4:00 pm Sunday 10:00 am - 2:00 pm Turnaround Time**: • Solid Tumor Chromosome Analysis: 8-28 days • Paraffin Embedded Tissue FISH: 3-8 days • Products of Conception Chromosome Analysis: 9-21 days • Tissue Chromosome Analysis: 9-21 days • Routine Array CGH:14-21 days Specimen Collection Supplies: Sterile tube with sterile tissue culture media Biohazard Safety Bag Specimen Collection: Obtain sample under sterile conditions. If there is identifiable tissue in a POC, send chorionic villi. Stillbirth-if possible send fascia lata, lung, or kidney. Use separate containers with sterile media and label the material. If material is small and unidentifiable, send entire sample.

Note: Do Not Send Entire Fetus Note: Do Not Place Sample in Formalin, Formaldehyde, or Alcohol

*For Array CGH: collect 15-20mg of tissue in sterile media or 2 T-25 flasks that are 90%-100% confluent Specimen Handling: Refrigerated – send sample in a cooler Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Cytogenetics Specimen Requisition Transportation: Deliver/send to laboratory as soon as possible Comments / Special n/a Instructions: Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Improper fixation of specimen Retention Time of Specimen: 2 weeks after final report is issued Laboratory Subsection: Cytogenetics - UWMC **Turnaround times are averaged; some cases may be delayed due to closer than usual cell growth, incomplete paperwork, or other circumstances beyond the Cytogenetics Laboratory’s control.

8-6 8.7 Urine

Day(s) / Time (s) Performed: Monday- Friday 8:00 am - 5:00 pm Saturday 8:00 am - 4:00 pm Sunday 10:00 am - 2:00 pm Turnaround Time**: • Urovysion FISH: 8-10 days Specimen Collection Supplies: ThinPrep Cytolyt Collection Cup or Sterile Jar Biohazard Safety Bag Specimen Collection: Obtain 40-100 cc of urine in a sterile Collection Cup or a Sterile Jar. Transfer to a Thinprep Cytolyt collection cup Specimen Handling: Refrigerated Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Cytogenetics Specimen Requisition Transportation: Deliver/send to laboratory as soon as possible Comments / Special n/a Instructions: Rejection Criteria: • Inadequate Information/missing requisition • Unlabeled/mislabeled specimen • Improper fixation of specimen Retention Time of Specimen: 2 weeks after final report issued Laboratory Subsection: Cytogenetics- UWMC **Turnaround times are averaged; some cases may be delayed due to closer than usual cell growth, incomplete paperwork, or other circumstances beyond the Cytogenetics Laboratory’s control.

8-7 8.8 Biliary Duct Brushing

Day(s) / Time (s) Performed: Monday – Friday 8:00 am - 5:00 pm Turnaround Time**: • FISH: 7-10 days Specimen Collection Supplies: ThinPrep vial containing 20ml PreservCyt or Cytolyt solution Biohazard Safety Bag Specimen Collection: Minimum 20ml Specimen Handling: Room Temperature Specimen Requirements: • Labeled with two (2) patient identifiers • Completed Mayo Clinic Specimen Requisition Transportation: Deliver/send to Cytogenetics Laboratory as soon as possible Comments / Special This test is sent out to the Mayo Clinic. Deliver specimens directly Instructions: to the UWMC Cytogenetics Laboratory for coordinating appropriate send out protocol Rejection Criteria: • Specimen quantity below 20ml • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Improper fixation of specimen Retention Time of Specimen: Retained at Mayo Clinic until FISH test is reported Laboratory Subsection: Mayo Clinic **Turnaround times are averaged; some cases may be delayed due to closer than usual cell growth, incomplete paperwork, or other circumstances beyond the Cytogenetics Laboratory’s control.

8-8 Additional Testing Services 9.1 Electron Microscopy Services:

Specimen for Electron Microscopy (Primary Cilia, Skin, Renal, Muscle, Nerve and Lung)

Day(s) / Time (s) Performed: Monday - Friday 7:00 am –5:00 pm Turnaround Time**: Three (3) days Specimen Collection Supplies: • EM fixative (Half-Strength Karnovsky's Fixative or 3% Glutaraldehyde) • Blue Top Tissue Collection Vial • Blade • Dental Wax Plate • Nasal Brush (same type used for cervical brush) for cilia case. • Biohazard Safety Bag Specimen Collection: Immediately after the biopsy is obtained, place the specimen into a vial of EM fixative and send it to the EM Lab. The specimen should be free of blood or extra connective tissue.

For Cilia brushing, put the entire brush in the vial containing EM fixative.

*When cutting the tissue into smaller pieces, avoid crushing. Specimen Handling: Refrigerate Specimen Requirements: • Smaller pieces, 1-2 mm in one side • Specimen must be in EM fixative • Cannot be dried out • Specimen Container labeled with two (2) patient identifiers • Completed Specimen Requisition Transportation: Keep refrigerated before and during shipping (e.g. ship in crushing ice in a Styrofoam container). Do not freeze the tissue. Comments / Special • Specimen should be free of blood or extra connective tissue. Instructions: EM fixative can be obtained from the EM lab at UWMC. Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Improper fixation method used • Tissue is dried out Retention Time of Specimen: Two (2) Months After Final Report is Issued Laboratory Subsection: Electron Microscope – UWMC **Turnaround times varies depending on multiple specimen and laboratory factors

9-1 9.2 DNA Flow Cytometry

Specimens for DNA Flow Cytometry (Tumor/Tissue Biopsies): Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm

For questions regarding submission of specimens for DNA Flow Cytometry, please contact Montlake Front Office at 206-598-6400.

9-2 Outside Slides/Block Review Services

10.1 Slide Reviews (UW Medicine Patients) Slide Consults (External consultation with UW Medicine Pathologists)

Day(s) / Time (s) Performed: Monday - Friday 8:00 am - 5:00 pm Turnaround Time**: 2-4 working days Specimen Collection Supplies: n/a Specimen Collection: As appropriate, the following specimens are submitted: • Paraffin tissue blocks • Slides Specimen Handling: Room Temperature Specimen Requirements: • Pathology Service Request Form completed by requesting service • Pathology Report and/or Gross Description from outside facility that include patient’s name, date of birth, and the outside facility accession number • Materials labeled with two patient identifiers. Transportation: Transport via trackable method of transport, such as Federal Express. Comments / Special n/a Instructions: Rejection Criteria: • Inadequate information/missing requisition • Unlabeled/mislabeled specimen • Demographic information/outside reports do not match patient information on requisition • Materials received are damaged and unable to be repaired Retention Time of Specimen: 45 Days Laboratory Subsection: Pathology Accessioner Office **Turnaround times varies depending on multiple specimen and laboratory factors

10-1 Requisitions/Forms

Form Name Applicable Section(s) UH 0070 – Cytology & Molecular Specimen Requisition Forms Cytology, Molecular UH 0657 – Histology Services Specimen Collection Forms Histology DNA Flow Cytometry Specimen Requisition Forms DNA Flow Cytometry Neuropathology Service Form - Neuro Referral Neuropathology Clinical_Cytogenomics_Lab_Requisition_Constitutional Cytogenetics Clinical_Cytogenomics_Lab_Requisition_Neoplasia Cytogenetics Cytogenetics_and_Genomics_Research_Service_Request_Form Cytogenetics Neoplasia_IFISH_Supplemental_Request_Form_10-24-19 Cytogenetics General Pathology Consult Review Request Form PSR General Outside Slide Reviews / 1_7_13 Consultations General Consults / Reviews Breast & Gynecological Pathology Bone & Soft Tissue Cardiac Tissue Cytology and Cervical Dermatopathology Electron Microscopy Gastrointestinal (GI) Pathology Genitourinary (GU) Pathology Pathology IHC & Molecular - IHCMOL_PSR_2019 Immunohistochemistry (IHC) and Immunofluoresence (IF)

Renal Transplant Biopsy Requisition Form Renal Pathology Native Kidney Biopsy Requisition Form Renal Pathology

11-1 CYTOLOGY REQUEST (*SEE REVERSE FOR SPECIMEN COLLECTION TECHNIQUES/ADD’L INFO) ACCESSION NO. HISTORY AGE LMP Birth Control Pills Previous Irradiation Cytology Lab Use Only Intrauterine Device Chemotherapy MENOPAUSAL DES Exposure Clinical Cancer PREGNANT NOW? Trimester #___ Estrogen Therapy Previous Abnormal Cytology POST-PARTUM? HPV Vaccination Previous HPV-HR Positive PERTINENT CLINICAL DATA DATE/TIME COLLECTED

SPECIMEN SOURCE Endocervical Sputum Peritoneal Wash Needle Aspirate: Site: Ectocervical Bronchial Wash Pericardial Fluid Vaginal Pool Bronchial Brush Urine (Voided) Vaginal Wall Esophageal Brush Urine (Cath) Other: Site: Pleural Fluid Bladder Wash Ascitic Fluid CSF (Cerebrospinal fluid) NOT for lymphoma/leukemia evaluation - See reverse page for instructions. DIAGNOSIS CODE REQUIRED: GYN TEST REQUESTS FROM LIQUID PAP MEDIA [ONLY MOST COMMON LISTED. Write in code(s) if not listed below] MARK ALL THAT APPLY PAP TEST – SCREENING (LOW RISK): Z01.411 Routine gynecologic examination with abnormal findings CYTOLOGY SCREENING / PAP Z01.419 Routine gynecologic examination without abnormal findings Z12.4 Screening for malignant cervical neoplasia Z12.72 Screening for malignant vaginal neoplasia HPV TESTING Z12.89 Screening for malignant neoplasms (total hysterectomy) HPV SCREENING1 (Reflex if ASC-US) PAP TEST – SCREENING (HIGH RISK): HPV SCREENING1 (Co-Test) Z77.9 Other (suspected) exposures to hazards to health Z92.89 Personal history of other medical treatment 1 High Risk HPV types included are 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 & DIAGNOSTIC: 68. Genotyping for HPVs 16 and 18 is integrated into testing and reporting. Z85.41 Personal history of malignant neoplasm of cervix uteri C53.9 Malignant neoplasm of cervix uteri, unspecified CHLAMYDIA / GONORRHEA C54.1 Malignant neoplasm of endometrium D06.9 Carcinoma in situ of the cervix, unspecified CHLAMYDIA N87.9 Dysplasia of cervix (excludes CIS and CIN III) GONORRHEA N92.6 Irregular menstruation, unspecified N93.9 Abnormal uterine and vaginal bleeding, unspecified CHLAMYDIA / GONORRHEA DIAGNOSIS CODE (REQUIRED): R87.610 ASC-US Pap R87.611 ASC-H Pap Z01.411 Routine gynecologic examination with abnormal findings R87.612 LGSIL Pap Z01.419 Routine gynecologic examination without abnormal findings R87.613 HGSIL Pap Z11.3 Screen for Venereal Disease N76.0 Acute vaginitis R87.810 Positive High Risk HPV N76.1 Subacute and chronic vaginitis R87.615 Unsatisfactory Pap Test Other: _____ Other ______

ATTENDING PHYSICIAN UWP # AT (SERVICE) M.D. PHONE #

FOR USE BY CYTOLOGY ONLY SATISFACTORY CYTOTECHNOLOGIST COMMENTS SPECIMEN DESCRIPTION UNSATISFACTORY NEGATIVE ABNORMAL:

PATHOLOGIST COMMENTS CYTOPREPARATION Endocervicals/Metaplastics SMEARS CCF THIN PREP PRESENT ATROPHIC CELL BLOCK SPECIAL STAIN ABSENT NOT APPLICABLE

CYTOTECHNOLOGIST DATE PATHOLOGIST DATE

UW Medicine Harborview Medical Center – University of Washington Medical Center UW Neighborhood Clinics – Valley Medical Center University of Washington Physicians Seattle, Washington PLACE PATIENT LABEL HERE CYTOLOGY REQUEST

DO NOT SCAN OR UPLOAD TO THE MEDICAL RECORD

UH0070 REV JAN 20 HMC PMM# 1667 Specimen Collection for Cytology Harborview Medical Center (206) 744-0355, 744-4635, or 744-4279

To facilitate optimal preparation and speed results, please bring specimens to Cytology Laboratory at HMC (NJB Bldg. Room 2NJ244) or Pathology Office (Room BB220) at University of Washington Medical Center by 3:45 p.m. Monday – Friday.

To request a fine needle aspirate (performed by a Cytopathologist), please call (206) 744-3145.

SPECIMENS must be properly labeled with patient name and hospital number and sent in biological safety bags. They must be accompanied by a completed requisition with name, date of birth, hospital number, referring provider, appropriate boxes checked, and clinical information provided. FORMALIN IS NEVER AN APPROPRIATE CYTOLOGY FIXATIVE. See below for directions.

GYN Label PreservCyt vial with patient’s name and hospital number. Obtain adequate sample from ectocervix and endocervical canal using plastic spatula and endocervical brush. Rinse vigorously 10 times in solution to remove any residual sample from spatula and brush. Discard collection device(s). Tighten cap and place vial and requisition in bag for transport to laboratory.

If conventional smear is desired, label glass slide and immediately place into 95% ethanol fixative. Label fixative container, mark appropriate boxes on requisition, and place both in bag for transportation to laboratory. Sputum Send fresh unfixed early morning deep cough specimen as soon as possible. Three consecutive early morning specimens increase the yield of malignant cells. If a delay is anticipated, please refrigerate.

Sputum for PCP Send only induced specimens, non-induced specimens will not be processed for PCP.

Bronchial Washings Send fresh, unfixed specimens to laboratory immediately. Refrigerate if delay in transport is anticipated.

Bronchial Brushing Cut off brush end and send in physiological saline ASAP to the laboratory. Refrigerate if delay is unavoidable.

Body Cavity Fluids Add 0.5 ml EDTA to clean container for each 100 mls collected. Optimum volume is at least 100-300 mL (up to 1 (peritoneal wash, pleural, liter if available). Send to laboratory immediately. Refrigerate if delay in transport is anticipated ascites, pericardial, etc.) Urine (voided) Please send “clean catch” specimen. Do Not send first morning void. Optimum volume is 100 mls. Send specimen immediately to laboratory or refrigerate if slight delay is unavoidable. If a delay of 24 hours or more is anticipated, add equal volume 50% ethanol.

Urine (catheterized) Send fresh specimen to laboratory or refrigerate if slight delay is anticipated. If longer delay is anticipated, add equal volume 50% ethanol.

Bladder Washings Send fresh specimen immediately to laboratory. Refrigerate if delay is necessary. Add equal volume 50% ethanol if delay is more than 24 hours.

CSF Cerebrospinal fluid is a highly perishable specimen; notify laboratory if specimen is to be obtained in the afternoon. Minimum volume necessary for processing is one ml. Send to laboratory immediately. Refrigerate if delay is unavoidable. If long delay is anticipated (e.g. over the weekend), record the volume and deposit the specimen in CytoLyt solution, which can be obtained from the Cytology Laboratory (744-4279) or the UWMC Pathology Gross Room (NW211). *Send CSF for lymphoma/leukemia evaluation directly to Hematopathology (206)288-7060.

Fine Needle Fix slides immediately in 95% ethanol (ETOH). Rinse needle in physiological saline and transport immediately to Aspiration laboratory. If delay is required add equal volume 50% ethanol. You may also deposit and rinse entire sample in CytoLyt solution. CytoLyt solution can be obtained from Cytology Laboratory (744-4279) or the UWMC Pathology Gross Room (NW211). If FNA assistance is required, call Pathology (744-3145) or Cytology (744-4635).

Thyroid Aspirates Fix slides immediately in 95% ethanol (ETOH). If the aspirate is markedly bloody, deposit and rinse entire sample in CytoRich Red Collection fluid. If assistance is needed, please call Pathology (744-3145) or Cytology (744-4635).

Misc. Aspirations Send fresh unfixed specimen to laboratory as soon as possible. Refrigerate if delay is anticipated. (cysts, joint, etc) Misc. Brushings Cut off brush end and place in CytoLyt solution immediately. CytoLyt solution can be obtained from Cytology (renal, gastric, bile duct, Laboratory (744-4279) or UWMC Pathology Gross Room (NW211). endocervical cytobrush, etc.) Misc. Smears Fix smears immediately in 95% ethanol.

ABN (Advanced Beneficiary Notice): For Medicare patient(s), please check that ABN has been signed to facilitate patient billing if Medicare does not cover procedure (Medicare may cover only one low-risk screening pap every 2 years). ABN must be signed in order to bill patient.

Diagnosis/ICD-10 Code: Specify the diagnosis code to indicate medical necessity. (Rev. JAN 20) ANATOMIC PATHOLOGY CONSULT REQUEST ALL FIELDS ON THIS FORM ARE MANDATORY

Accession No. (For Pathology Use Only) HMC SCCA Outpatient Specimen UWMC - NW Originated at: Inpatient Operating Room # Date & Time Specimen Removed: UWMC - MTL AM PM Form Prepared By: Phone #: HSCT Patient (Send to SCCA) (Please Print Clearly)

Requesting Provider & Others Needing NPI # Department Pager Telephone # Pathology Report 1. 2. 3. MANDATORY: CLINICAL HISTORY, PLANNED PROCEDURE(S), DIFFERENTIAL DIAGNOSIS: (Include ICD code if known) Hold for Risk Management:

Previous surgery: Chemo or radiation therapy: Transplant (type & date): Last menstrual period (date): Other: SPECIMEN: Specify EXACT Anatomical Source Liver Biopsy Improperly labeled specimens may not be accepted as per APOP HMC 65.1/UWMC 65.2, 65.3 Liver transplant biopsy Liver diagnostic biopsy Liver metastatic A. disease biopsy Liver Enzymes B. Billirubin Alk Phos GGT C. AST ALT D. Flow Cytometry Studies Hematopatholgy Flow Cytometry E. DNA Flow Cytometry Intraoperative Consultation: (For Pathology Use Only) SEE FINAL REPORT Frozen Section Gross Only Imprint/Smear

Tissue Saved for: ( ) IHC FLOW FROZEN HEME CYTOGEN EM (Designate Specimen A, B, C, etc.) Fixative

RESIDENT SIGNATURE PRINT NAME FELLOW’S SIGNATURE PRINT NAME

 I reviewed the specimen(s) and the interpretation was made by me.  I reviewed the specimen(s) and agree with the resident’s interpretation.

PHYSICIAN SIGNATURE PRINT NAME PAGER NPI DATE TIME

UH0657 REV JAN 20 SPECIMEN (SPECIFY EXACT ANATOMICAL SOURCE) Improperly labeled specimens may not be accepted as per APOP HMC 65.1/UWMC 65.2, 65.3

X. FOR ADDITIONAL LINES, USE ANOTHER FORM METHOD OF SUBMITTING SPECIMEN All tissue specimens should be submitted using appropriate procedure as stated in the Specimen Handling Manual. Fresh, unfixed tissue should be delivered immediately to the Pathology Department.

Pathology Consultations, Frozen Sections, & Flow Cytometry, Call Pathology: HMC – 206-731-3145 SCCA – 206-288-1355 UWMC- MTL – 206-598-6400 UWMC – NW - 206-368-1779 NOTE: Improperly Labeled Specimens Will Not Be Processed Until Corrected Label must include: Name, Patient Number, Age, Date, and Specimen Source

PHYSICIAN SIGNATURE PRINT NAME PAGER NPI DATE TIME

UH0657 REV JAN 20 1959 NE Pacific St, Room BB220, Seattle, WA 98195 Phone: 206-598-6400 | Fax: 206-598-8049 UWPathology.org For UW Pathology use MRN: Accession #

First Name MI Last Name Institution Name

Sex DOB SSN Institution Address nstitution Patient Address City State Zip

City State Zip Person Completing Form Patient Information

Requesting I

Patient Phone # Outside Facility Patient ID # Phone Fax  

Requesting Physician (primary): Phone Fax NPI #

Referring Physician/Surgeon: Phone Fax NPI #

Referring Pathologist: Phone Fax NPI # Send Reports to Additional reports to: Phone Fax NPI # 

Payment Patient Insurance* (If outpatient) Self-Pay (No insurance) Institution/Client Billing Split Billing / Medicare* (Pro to Patient, Tech to Client) Options: *Medicare Billing policy does not permit tech claims on laboratory testing for hospital inpatients/outpatients. These tech charges will be billed to the requesting institution. Primary Insurance Secondary Insurance

ID/Policy # Group # ID/Policy # Group #

Insurance Address Phone Insurance Address Phone

City/State/Zip City/State/Zip Billing InformationBilling

 Insured's Name DOB Relation to Pt: Insured's Name DOB Relation to Pt:

Note: For Fresh or Frozen tissue, refer to shipping kit materials and or UWPathology.org for DNA Flow Cytometry preparation and shipping instructions.  Specimen Information  Attach: Report Medium: # Outside Accession/Case #: Specify Biopsy Location or Tissue Source: Collect Date Fresh, Frozen, Patient Information: Paraffin Blocks UC Fresh, Frozen, Crohn's Colitis Paraffin Blocks IBD Fresh, Frozen, Barrett's Esophagus Paraffin Blocks POC Fresh, Frozen, Other (please specify): Paraffin Blocks Fresh, Frozen, Paraffin Blocks If you run out of room, please use a second form and attach Additional Patient History (eg: Disease Process) :

 Physician Signature Required Accessioned By: Submitting a specimen with this requisition form indicates familiarity and agreement with applicable Reference Laboratory Services policies found at http://pathology.washington.edu/clinical/servicerequest Signature: Date:

DNA FLOW – 1/7/14 908 Jefferson St, Room 2NJ244, Seattle, WA 98104 Phone: 206-744-3145 | Fax: 206-744-8240 | UWPathology.org For UW Pathology use MRN: Accession #

First Name MI Last Name Institution Name

Sex DOB SSN Institution Address

Patient Address City State Zip

City State Zip Person Completing Form Patient Information

Patient Phone # Outside Facility Patient ID # Requesting Institution Phone Fax n o

Requesting Physician (primary): Phone Fax NPI #

Referring Physician/Surgeon: Phone Fax NPI #

Referring Pathologist: Phone Fax NPI # Send Reports to Send Additional reports to: Phone Fax NPI # p

ID/Policy # Group # ID/Policy # Group #

Insurance Address Phone Insurance Address Phone

City/State/Zip City/State/Zip Billing Information

q Insured's Name DOB Relation to Pt: Insured's Name DOB Relation to Pt:

Note: For Fresh or Frozen tissue refer to shipping kit materials and or UWPathology.org for preparation and shipping instructions. r Specimen Information Transport Medium: Quantity Outside Accession/Case #: Specimen Source (be specific ex: R/L Sural Nerve, R/L Occipital Lobe, etc): Collection Date: Slides Blocks Fixed Fresh (on wet ice) Fixed for EM Frozen (on dry ice) Slides Blocks Fixed Fresh (on wet ice) Fixed for EM Frozen (on dry ice) Slides Blocks Fixed Fresh (on wet ice) Fixed for EM Frozen (on dry ice) Slides Blocks Fixed Fresh (on wet ice) Fixed for EM Frozen (on dry ice)

FISH/IHC Testing (optional): Additional Comments or Related History (Not required): FISH: IHC (write in): 1p/19q Deletion PTEN Deletion EGFR Amplification

s Physician Signature Required For UW Pathology Use Submitting a specimen with this requisition form indicates familiarity and agreement with applicable Reference Laboratory Services policies found at Accessioned by: Time Stamp: http://pathology.washington.edu/clinical/servicerequest Signature: Date:

Neuro Referral PSR 1/7/14 1959 NE Pacific1959 NE St, Pacific1959Room NE St, PaciﬁcNWRoom-125 St, NWRoom, Seattle,-125 NW-125, Seattle,WA, 98195Seattle, WA WA 98195 98195 Phone: 206Phone:-598 -2064488Phone:-598 | 206-598-4488 - 4488Fax: 206 | Fax:-598 | 206Fax:-2610 -206-598-2610598-2610 UWPathology.org/clinical/cytogenetics UWPathology.org/clinical/UWPathology.org/clinical/cytogeneticscytogenetics For UW Pathology use CONSTITUTIONAL TESTFor UW PathologyMRN: use Accession # Clear Form MRN: Accession # ClearREQUEST Form FORM First Name MI Last Name Institution Name First Name MI Last Name Institution Name First Name MI Last Name Institution Name Sex DOB SSN Institution Address Sex DOB SSN Institution Address Sex DOB SSN Institution Address Patient Address City State Zip PatientPatient Address Address City City State Zip State Zip City State Zip Person Completing Form

City State Zip Person Completing Form

City Patient Information State Zip Person Completing Form

Patient Phone # Outside Facility Patient ID # Requesting Institution Phone Fax  Requesting Institution Patient Information Patient Patient Information 

PatientPatient Phone Phone# # OutsideOutside Facility Facility Patient PatientID # ID Requesting Institution Phone Phone Fax Fax 2 1  Requesting Physician (primary):  Phone Fax NPI #

RequestingRequesting Physician Physician (primary): (primary): Phone Phone Fax Fax NPI # NPI# Referring Physician/Surgeon: Phone Fax NPI # Referring Physician/Surgeon: Phone Fax NPI# Referring Physician/Surgeon: Phone Fax NPI # Referring Pathologist: Phone Fax NPI # Referring Pathologist: Phone Fax NPI#

Send ReportsSend to Phone Fax NPI # Referring Pathologist:Additional reports to: Phone Fax NPI # Send Reports to  Additional reports to: Phone Fax NPI# 3 Send ReportsSend to Additional reports to: Phone Fax NPI #

 Payment Patient Insurance* (If outpatient) Self-Pay (No insurance) Institution/Client Billing Split Billing / Medicare* (Pro to Patient, Tech to Client) PaymentOptions: Patient*Medicare Insurance* Billing (If outpatient)policy does not permit Self-Pay tech claims (No on insurance) laboratory testing forInstitution/Client hospital inpatients/outpatients. Billing SplitThese Billing tech charges / Medicare* will be bille(Prod toto Patient,the requesting Tech toinstitution. Client) Primary Insurance Secondary Insurance PaymentOptions: Patient*Medicare Insura Billingnce policy* (If odoesutpatient) not permit techSelf claims-Pay (No on laboratoryinsurance) testingInstitution/Client for hospital inpatients/outpatients. Billing Split These Billing tech /charges Medicare* will be (Probilled to to Patient, the requesting Tech to institution. Client) Options:Primary Insurance*Medicare Billing policy does not permit tech claims on laboratory testing for hospital inpatients/outpatients.Secondary Insurance These tech charges will be billed to the requesting institution. ID/Policy # Group # ID/Policy # Group # Primary Insurance Secondary Insurance ID/Policy # Group # ID/Policy # Group # Insurance Address Phone Insurance Address Phone ID/Policy # Group # ID/Policy # Group # Insurance Address Phone Insurance Address Phone City/State/Zip City/State/Zip Billing InformationBilling Insurance Address Phone Insurance Address Phone

City/State/Zip City/State/Zip Insured's Name DOB Relation to Pt: Insured's Name DOB Relation to Pt:

City/SBilling Information tate/Zip City/State/Zip

Billing InformationBilling Insured’s Name DOB Relation to Pt: Insured’s Name DOB Relation to Pt: 4

 Note: For sample collection requirements see http://www.UWPathology.org/clinical/cytogenetics Note:Insured's For sampleName Specimen collection Type requirements see DOBwww.pathology.washington.edu/patient-care/cytogenetics-collectionDate Obtained:Relation to Pt: Insured's Name  Tests DOB RelationSTAT to Pt: ROUTINE Prenatal Please Complete for Prenatal Specimens: Chromosomal Microarray Analysis (CMA) (CGH/SNP) Amniotic Fluid Constitutional Targeted Microarray (CTM) Reflex to Karyotype Note: 5 For Specimen sample collection Type requirements see http://www.UWPathology.org/clinical/cytogeneticsGestational Age: 6 Diagnosis or Indication for Testing Chorionic Villi Date obtained: Constitutional High-density Microarray (CHM) By Dates:  Specimen Type Date Obtained:  Tests STAT ReflexROUTINE to FISH or IFISH Peripheral BloodPrenatal Cord Blood Please attachNeo copyplasia of pedigreeGenomic if indication Microarray is Family(NGM) History of… Prenatal Products of ConceptionPlease CompleteBy for Ultrasound: Prenatal Specimens: Chromosomal Microarray Analysis (CMA) (CGH/SNP) ICD-10 Code:Chromosome Analysis Reflex to Karyotype Amniotic Amniotic Fluid FlTissueuid (Gestational-Fetal Age:Gestational Age: ) ConstitutionalRoutine TargetedKaryotyping Microarray (CTM)Family Follow-up Reflex to Microarray Chorionic Villi Constitutional High-density Microarray (CHM) CTM CHM NGM Fetal Sex: Male ByFemale Dates: Site: ______Mosaicism for: ______Prenatal Chorionic Cord VilliBlood (Gestational Age: ) Neoplasia Genomic Microarray (NGM) Reflex to FISH or IFISH Postnatal FISH and IFISH- Please see Neoplasia IFISH Supplemental Request Form or call for probe availability Products of Conception By Ultrasound: Products ofBlood ConceptionPostnatal (Gestational Cord Age: Blood Skin Biopsy + Site: ______) ChromosomeIFISHAnalysis for Aneuploidy (13,18,21,X,Y) Tissue-Fetal Routine KaryotypingFISH or IFISH for: ______Family Follow-up ______Reflex to______Microarray In Heparin in EDTA (for PCR or Microarray) Fetal Sex: Male Female Site: ______Neoplasia IFISH: Complete the Neoplasia IFISH SupplementalCTM CHM RequestNGM Form Fetal TissueNeoplasia (Site: ) Mosaicism for: ______Bone Marrow Tumor Other: FISH and IFISHOther- Please see Neoplasia IFISH Supplemental Request Form or call for probe availability Postnatal Umbilical Cord Blood Blood PostnatalBone Core Cord Biopsy Blood SkinParaffin Biopsy Blocks/Slides + Site: ______(FFPE) IFISH for AYneuploidy-PCR for Male(13,18,21,X,Y) Infertility Breakage Study (Control Required) Leukemic Blood Urine FISH or IFISHOther:for: ______Skin BiopsyIn Heparin (Site: in EDTA (for PCR or Microarray) ) Neoplasia IFISH: Complete the Neoplasia IFISH Supplemental Request Form Neoplasia Saliva  Clinical Diagnosis/Indications Bone MarrowClinical History: Tumor Other: Other Diagnosis: Bone Paraffin Core Biopsy Blocks/Slides Paraffin(Site: Blocks/Slides (FFPE) ) Y-PCR This for is Male a family Infertility follow-up studyBreakage Study (Control Required) Leukemic Blood Urine Other: ______(Name of proband: ) DNA  Clinical Diagnosis/Indications Clinical History: *** SEE PAGE 2 FOR TESTS *** Diagnosis:  Physician Signature Required Submitting a specimen with this requisition form indicates familiarity and agreement with applicable Reference Laboratory Services policies found at http://pathology.washington.edu/clinical/servicerequest Ordering ProviderSignature: Signature Required Date: Submitting a specimen with this requisition form indicates familiarity and agreement with applicable Reference Laboratory Services policies found at http://pathology.washington.edu/clinical/servicerequest PSR CYTOGEN- 1/7/14  Physician Signature Required SignatureSubmitting a specimen with this requisition form indicates familiarity and agreement with applicable Reference Laboratory Services policies found at http://pathology.washington.edu/clinical/servicerequestDate Signature: Date:

PSR CYTOGEN- 1/7/14 1 of 2 7 Test(s) Requested STAT ROUTINE

Interphase FISH for common aneuploidies (13, 18, 21, X, Y)

Interphase FISH after pregnancy loss (13, 15, 16, 18, 21, 22, X, Y)

Metaphase FISH for: 1p36.1 deletion Prader-Willi syndrome (15q11.2 deletion) 15q11-q13 duplication (autism) SHOX-related haploinsufficiency 22q11.2 deletion (VCFS/DiGeorge) Smith-Magenis syndrome (17p11.2 deletion) 22q11.2 duplication Sotos syndrome (5q35 deletion) Angelman syndrome (15q11.2 deletion) SRY (46,XX testicular DSD/46,XY DSD/46,XY CGD) Cri du Chat syndrome (5p deletion) Subtelomeres (Specify: ) Kallmann syndrome Williams syndrome (7q11.23 deletion) Langer-Giedion (8q24 deletion) Williams-Beuren region duplication (7q11.23 duplication) Miller-Diecker syndrome (17p13.3 deletion) Wolf-Hirschhorn (4p deletion) Pallister-Killian syndrome (iso12p mosaicism) X-linked ichthyosis (STS deletion) Potocki-Lupski syndrome (17p11.2 duplication) Other (Specify: )

Cytogenomic Microarray Analysis (CMA/CGH/CGAT/SNP Array) Report all findings Do not report variants of uncertain clinical significance

ddPCR (droplet digital PCR) for deletion or duplication (Specify: )

Routine G-banded chromosome analysis and karyotyping

Mosaicism study by chromosome analysis and karyotyping Mosaicism for:

Limited parental follow-up study by chromosome analysis and karyotyping

Y chromosome deletions by PCR for male infertility

Grow cell cultures for sendout Sendout instructions:

Reflex Testing

If is Normal then reflex to Abnormal

Patient Insurance Billing Consent I authorize the Clinical Cytogenomics Laboratory (CCL) to release to my designated insurance carrier, health plan, or third party administrator the information on this form and any other information provided by my health care provider necessary for reimbursement. I assign and authorize insurance payments to CCL. I understand my insurance carrier may not approve and reimburse my medical genetic services in full due to usual and customary rate limits, beneft exclusions, coverage limits, lack of authorization, medical necessity, or otherwise. I understand I am responsible for fees not paid in full, co-payments, and policy deductibles except where my liability is limited by contract or State or Federal law. A duplicate or faxed copy of this authorization is considered the same as the original document.

Patient Signature Date

07.05.2018 2 of 2 1959 NE Pacific1959 NE St, Pacific1959Room NE St, PaciﬁcNWRoom-125 St, NWRoom, Seattle,-125 NW-125, Seattle,WA, 98195Seattle, WA WA 98195 98195 Phone: 206Phone:-598 -2064488Phone:-598 | 206-598-4488 - 4488Fax: 206 | Fax:-598 | 206Fax:-2610 -206-598-2610598-2610 UWPathology.org/clinical/cytogenetics UWPathology.org/clinical/UWPathology.org/clinical/cytogeneticscytogenetics For UW Pathology use NEOPLASIA TEST For UW PathologyMRN: use Accession # Clear Form MRN: Accession # ClearREQUEST Form FORM First Name MI Last Name Institution Name First Name MI Last Name Institution Name First Name MI Last Name Institution Name Sex DOB SSN Institution Address Sex DOB SSN Institution Address Sex DOB SSN Institution Address Patient Address City State Zip PatientPatient Address Address City City State Zip State Zip City State Zip Person Completing Form

City State Zip Person Completing Form

City Patient Information State Zip Person Completing Form

Patient Phone # Outside Facility Patient ID # Requesting Institution Phone Fax  Requesting Institution Patient Information Patient Patient Information 

PatientPatient Phone Phone# # OutsideOutside Facility Facility Patient PatientID # ID Requesting Institution Phone Phone Fax Fax 2 1  Requesting Physician (primary):  Phone Fax NPI #

City/State/Zip City/State/Zip Insured's Name DOB Relation to Pt: Insured's Name DOB Relation to Pt:

City/SBilling Information tate/Zip City/State/Zip

Billing InformationBilling Insured’s Name DOB Relation to Pt: Insured’s Name DOB Relation to Pt: 4  Note: For sample collection requirements see http://www.UWPathology.org/clinical/cytogenetics Note:Insured's For sampleName Specimen collection Type requirements see DOBhttp://www.UWPathology.org/clinical/cytogeneticsDate Obtained:Relation to Pt: Insured's Name  Tests DOB RelationSTAT to Pt: ROUTINE Prenatal Please Complete for Prenatal Specimens: Chromosomal Microarray Analysis (CMA) (CGH/SNP) Amniotic Fluid Constitutional Targeted Microarray (CTM) Reflex to Karyotype 5 Specimen Type DateGestational obtained: Age: 6 Diagnosis or Indication for Testing Note: For sample Chorioniccollection Villi requirements see http://www.UWPathology.org/clinical/cytogenetics Constitutional High-density Microarray (CHM) By Dates:  Specimen Type Date Obtained:  Tests STAT ReflexROUTINE to FISH or IFISH Bone MarrowPrenatal Cord Blood ICD-10 Code:Neo plasia Genomic Microarray (NGM) Prenatal Products of ConceptionPlease CompleteBy for Ultrasound: Prenatal Specimens: Chromosomal Microarray Analysis (CMA) (CGH/SNP) Bone Core Biopsy Chromosome Analysis Reflex to Karyotype Amniotic FluidTissue-Fetal Gestational Age: ConstitutionalRoutine TargetedKaryotyping Microarray (CTM)Family Follow-up Reflex to Microarray Chorionic Leukemic Villi Blood Constitutional High-density Microarray (CHM) CTM CHM NGM Fetal Sex: Male ByFemale Dates: Site: ______Mosaicism for: ______Prenatal Cord Blood Neoplasia Genomic Microarray (NGM) Reflex to FISH or IFISH Fresh orPostnatal Frozen Tumor (Site: ) FISH and IFISH- Please see Neoplasia IFISH Supplemental Request Form or call for probe availability Products of Conception By Ultrasound: Paraffin Blocks/SlidesBlood Postnatal (Site: Cord Blood Skin Biopsy + Site: ______) ChromosomeDisease Phase:IFISHAnalysis for APre-treatmentneuploidy (13,18,21,X,Y) or Relapse Tissue-Fetal Routine KaryotypingFISH or IFISH for: ______Family Follow-up ______Reflex to______Microarray Urine In Heparin in EDTA (for PCR or Microarray) Post-treatment Fetal Sex: Male Female Site: ______MosaicismNeoplasia for: ______IFISH: Complete the Neoplasia IFISH SupplementalCTM CHM RequestNGM Form Other: Neoplasia Post-transplant Postnatal Bone Marrow Tumor Other: FISH and IFISHOther- Please see Neoplasia IFISH Supplemental Request Form or call for probe availability Blood PostnatalBone Core Cord Biopsy Blood SkinParaffin Biopsy Blocks/Slides + Site: ______(FFPE) IFISH for AYneuploidy-PCR for Male(13,18,21,X,Y) Infertility Breakage Study (Control Required) 7 Test(s) RequestedLeukemic Blood Urine FISH or IFISHOther:for: ______STAT ROUTINE In Heparin in EDTA (for PCR or Microarray) Neoplasia IFISH: Complete the Neoplasia IFISH Supplemental Request Form Neoplasia G-banded chromosomeClinical Diagnosis/Indications analysis and karyotyping Bone Neoplasia MarrowClinical Cytogenomic History: Tumor Microarray Analysis ( CMA / CGH / COther:GAT / SNP Array ) Other Diagnosis: Paraffin Blocks/Slides (FFPE) Y-PCR for Male Infertility Breakage Study (Control Required) Bone Single Core Neoplasia Biopsy IFISH (specify locus or gene) If: Normal Leukemic Blood Urine Other: ______Abnormal reflex to  Clinical Neoplasia Diagnosis/Indications IFISH Panel (check one) See http://www.pathology.washington.edu/clinical/cytogenetics/ for loci included in panels. Clinical History: Diagnosis: AML Eosinophilia T-cell ALL Bladder Cancer MDS / MPDPhysician (or CMML) Signature Required CLL or SLL Adult B-cell ALL Glioblastoma Submitting a specimen with this requisition form indicates familiarity and agreement with applicable Reference Laboratory Services policies found at http://pathology.washington.edu/clinical/servicerequest B-cellSignature: Lymphoma Multiple Myeloma Childhood ALL Other: Date:

Ordering Provider Signature Required PSR CYTOGEN- 1/7/14 SubmittingPhysician a specimen Signature with R thisequired requisition form indicates familiarity and agreement with applicable Reference Laboratory Services policies found at http://pathology.washington.edu/clinical/servicerequestSubmitting a specimen with this requisition form indicates familiarity and agreement with applicable Reference Laboratory Services policies found at http://pathology.washington.edu/clinical/servicerequest Signature: Date: Signature Date

PSR CYTOGEN- 1/7/14 01.25.2016 Cytogenetics and Genomics Laboratory Box 356100, 1959 NE Pacific St, Room NW125 University of Washington Medical Center Phone: 206-598-4488 FAX: 206-598-2610

CYTOGENETICS and GENOMICS RESEARCH SERVICE REQUEST FORM: USE FOR RESEARCH / NONCLINICAL CYTOGENETICS AND GENOMICS STUDIES

Please contact us for pricing

TEST SAMPLE TYPE  complete G-banding karyotype analysis (20 cells)  established cell line  abbreviated G-banding karyotype analysis (5 cells)  cell line ready to harvest  extended G-banding karyotype analysis (50 or more cells)  slides ready for analysis  specimen, blood or solid tissue, for setup/culture/harvest  FISH or IFISH ______ other (specify)______ Microarray analysis (human) human male  female mouse other______

IDENTIFYING INFORMATION (CELL LINE NAME, Passage etc.): ______

REASON FOR TESTING: ______

RULE OUT: ______

TEST ORDERED BY: ______

 Phone #:______

Email:______

DATE: ______

TEST NUMBER: ______

PRICE QUOTED: ______

CHARGE: Send bill to:______

Grant name:______

Grant #:______

 EMAIL REPORT TO: ______

 MAIL REPORT TO: Name:______

Department:______Box #:______

Address:______

 FAX REPORT TO: ______

Cytogenetics and Genomics Research Service Request Form 3 18 2013 Cytogenetics and Genomics Laboratory Room NW125 University of Washington Medical Center Phone: 206-598-4488 FAX: 206-598-2610

NEOPLASIA IFISH SUPPLEMENTAL REQUEST FORM Please CHECK the appropriate box, SIGN below and FAX to 206-598-2610

Patient Name:______Accession Number:______Block:______Collection date:______

Patient DOB: ______Sex:______Indication:______Specimen Source:______

Chromosome Chromosome Disease Gene Disease Gene abnormality abnormality AML □ t(8;21) □ RUNX1T1/RUNX1 Eosinophilia □ rea(4q12) □ SCFD2/LNX/ □ t(15;17) □ PML/RARA PDGFRA/KIT □ Panel □ inv(16)* □ CBFB* □ Panel □ rea(5q32) * □ PDGFRB* □ rea(11q23)* □ MLL* □ rea(8p12)* □ FGFR1* □ -5 or del(5q) □ EGR1/D5S23 □ inv(16)* □ CBFB* □ -7 or del(7q) □ D7S486/CEN7 □ t(6;9) □ DEK/NUP214 T-cell ALL □ rea(7q34)* □ TRB* □ inv(3) □ MECOM □ rea(14q11)* □ TRA and TRD* □ +8 □ CEN +8 □ Panel □ del(9p) □ CDKN2A/CEN9 □ t(9;22) □ BCR/ABL1/ASS1 □ rea(11q23)* □ MLL* □ -17 or del(17p) □ TP53 MDS/MPD (and □ inv(3)del(17p) □ MECOM Adult B-cell ALL □ del(9p) □ CDKN2A/CEN9 CMML) □ -5 or del(5q) □ EGR1/D5S23 □ t(9;22) □ BCR/ABL1/ASS1 □ -7 or del(7q) □ D7S486/CEN7 □ Panel □ rea(14q32)* □ IGH* □ Panel □ +8 □ CEN8 □ -17 or del(17p) □ TP53 □ -13 or del(13q) □ D13S319/13q34 □ t(1;19) □ PBX1/TCF3 □ del(20q) □ D20S108 □ rea(11q23)* □ MLL* □ -17 or del(17p) □ TP53 B-cell □ rea(3q27)* □ BCL6* Childhood ALL □ t(1;19) □ PBX1/TCF3 Lymphoma □ rea(8q24) * □ MYC * □ t(9;22) □ BCR/ABL1 □ t(11;14)* □ CCND1/IGH * □ rea(11q23)* □ MLL* □ Panel □ t(11;18) * □ BIRC3/MALT1 * □ t(12;21) □ ETV6/RUNX1 □ Panel □ t(14;18) * □ IGH/BCL2 * □ rea(12p13)* □ ETV6* □ t(8;14) * □ MYC/IGH* □ +4 □ CEN4 □ t(14;18) (MALT) □ IGH/MALT1 □ +10 □ CEN10 □ rea(14q32)* □ IGH* □ rea(18q21)* □ BCL2* Renal cell carcinoma □ rea(Xp11)* □ TFE3* □ abn(1p/1q) □ CDKN2C/CKS1B □ MYC ReflexTesting Breast cancer □ 17q ampli* □ ERBB2* □ If MYC abnormal, reflex to t(14;18) IGH/BCL2 & 3q27 BCL6 High Grade □ rea(3q27)* □ BCL6* Lung cancer □ rea(2p23)* □ ALK* □ Panel □ rea(8q24) * □ MYC* □ rea(6q22)* □ ROS1* □ t(8;14) * □ MYC/IGH* □ rea(7p12)* □ EGFR* □ t(14;18) * □ IGH/BCL2 * □ rea(7q34)* □ TRB* Sarcoma (Ewing) □ rea(22q12)* □ EWSR1* T-cell Lymphoma □ rea(14q11)* □ TRA and TRD* Sarcoma (synovial) □ rea(18q11)* □ SS18* □ i(7q) □ D7S486/CEN7 Sarcoma (osteo; soft tissue) □ 12q14.5-q15 ampli* □ MDM2* Hepatosplenic □ rea(14q32) □ TCL1A Rhabdomyosarcoma □ rea(13q14)* □ FOXO1* T-cell PLL Myxoid liposarcoma □ rea(16p11)* □ FUS* Myxoid & RC Liposarcoma □ rea(12q13)* □ DDIT3* CLL (or SLL) □ del(6q) □ MYB EMC □ rea(9q22.33q31.1)* □ NR4A3* □ del(11q) □ ATM □ Panel □ t(11;14)* □ CCND1/IGH* Bladder cancer □ Extra copies of 3, 7, □ CEN3, CEN7, □ +12 □ CEN12 17; del(9p21) CEN17, □ -13 or del(13q) □ D13S319/13q34 CDNK2A □ -17 or del(17p) □ TP53 Multiple □ abn(1p/1q) □ CDKN2C/CKS1B Glioblastoma □ del(1p)(19q)* □ 1p19q deletion* Myeloma □ t(4;14) □ FGFR3/IGH □ del(10q23)* □ PTEN* □ t(11;14)* □ CCND1/ IGH* □ Panel □ 7p12 ampli* □ EGFR* □ t(14;16) □ IGH/MAF □ 8q24 ampli* □ MYC* □ Panel □ -13 or del(13q) □ D13S319/13q34 ABC & NF □ rea(17p13)* □ USP6* □ -17 or del(17p) □ TP53/CEN17 Other □ □ Reflex Testing if indicated: □ rea(14q32)* □ IGH* * Indicates probe is validated on paraffin tissue (FFPE) and suspension cells Requesting Physician:______Referring institution:______Printed

Requesting Physician:______Copy Report to:______Signature Neoplasia IFISH Supplemental Request Form 10-24-19 1959 NE Pacific St, Room BB220, Seattle, WA 98195 Phone: 206-598-6400 | Fax: 206-598-8049 www.uwpathrequest.org/patient-care/ servicerequest For UW Pathology use MRN: Accession #

Last Name First Name MI Institution Name

Sex DOB SSN Institution Address

Patient Address City State Zip

City State Zip ing Institution Person Completing Form Send Patient Information Patient Phone # Patient ID # Phone Fax  

Requesting Physician (primary): Phone Fax NPI #

Referring Physician/Surgeon: Phone Fax NPI #

Referring Pathologist: Phone Fax NPI # Send Reports to Additional reports to: Phone Fax NPI # 

ID/Policy # Group # ID/Policy # Group #

Insurance Address Phone Insurance Address Phone

City/State/Zip City/State/Zip Billing InformationBilling

 Insured's Name DOB Relation to Pt: Insured's Name DOB Relation to Pt:

Note: For neuropathology services please use the form located at http://pathology.washington.edu/clinical/servicerequest/  Specimen Information  Attach: Report Demographics Medium: # Outside Accession/Case #: Specimen Source (ex: R/L calf skin, etc): Collect Date Case Type: Slide Review (UW/HMC/SCCA Patient) Slides, Blocks Dr: ______

Slides, Blocks Clinic: ______Appt Date: ______

Slides, Blocks Slide Consult (Non UW/HMC/SCCA Pt.)

------Slides, Blocks Breast/Gyn Pathology Bone/Soft Tissue Slides, Blocks Cardiac Cytology & Cervical Biopsies

Wet Tissue Dermatopathology Electron Microscopy If you run out of room, please use a second form and attach GI Pathology Additional Comments or Related History (Not required): GU Pathology Immunohistochemistry (IHC) Immunofluorescence Renal Other

 Physician Signature Required Submitting a specimen with this requisition form indicates familiarity and agreement with applicable Reference Laboratory Services policies found at http://pathology.washington.edu/clinical/servicerequest Signature: Date:

PSR GENERAL- 1/7/13 1959 NE Pacific St, Room BB220, Seattle, WA 98195 Phone: 206-598-6400 | UWPathology.org Fax: 206-598-8049 or 206-598-4928 with Accession #

Accession # (if filled, fax to 206-598-4928)

First Name MI Last Name Institution Name

Sex DOB SSN Institution Address

Patient Address Institution City State Zip

City State Zip Person Completing Form Patient Information

Requesting

Patient Phone # Patient ID # Phone Fax  

Requesting Physician (primary): Phone Fax NPI #

Referring Physician/Surgeon: Phone Fax NPI #

Referring Pathologist: Phone Fax NPI # Send Reports to Additional reports to: Phone Fax NPI # 

ID/Policy # Group # ID/Policy # Group #

Insurance Address Phone Insurance Address Phone

City/State/Zip City/State/Zip Billing InformationBilling

 Insured's Name DOB Relation to Pt: Insured's Name DOB Relation to Pt:

 Specimen Information Tissue Media Accession Number Block ID Slide ID Specimen Description Collection Date

 Prognostic Testing FISH Breast GI Lung Solid Tumor IHC Breast GI Lung Solid Tumor HER2neu HER2neu ALK/EGFR MSI

 Required if clinical not provided Hold for Risk Management Previous Surgery: Last Menstrual Period:

Chemo/Radiation Therapy: Other/Comments:

Transplant (type/date):

 Physician Signature Required For UW Pathology Use Submitting a specimen with this requisition form indicates familiarity and agreement with applicable Reference Laboratory Services policies found at Accessioned by: Time Stamp: http://pathology.washington.edu/clinical/servicerequest Signature: Date:

IHCMOL PSR 1/7/14 Renal Transplant Biopsy Requisition Form UWMC PATIENT NO. UWMC ACCESSION NO. Anatomic Pathology, Box 356100 Room BB220D Seattle, WA 98195-6100 PATIENT NAME DATE OF BIRTH Phone: (206) 598-6400 Supplies, Fax: (206) 598-8049 AGE SEX HEIGHT WEIGHT

1) TODAY’S DATE: ______

2) PREVIOUS BIOPSY: YES / NO (If YES, date of previous biopsy: ______)

3) TRANSPLANT DETAILS: Transplant date:______TYPE: ⁪ K alone, ⁪KP, ⁪other______

4) ORIGINAL CAUSE OF RENAL FAILURE: ______

5) INDICATION FOR Bx: ⁪Protocol biopsy or ⁪Clinical / Follow-up______

______

6) LABORATORY INVESTIGATION: Serum creatinine ______mg/dl ⁪ acute rise, ⁪chronic rise, ⁪failure to decline

Proteinuria YES / NO ______Donor specific antibodies YES / NO ______

7) Clinical Impression Definite Suspected Comments Acute Rejection Acute Tubular Necrosis Chronic Rejection Calcineurin inhibitor toxicity BK polyomavirus infection ⁪ Request SV40 Recurrent GN Severe Hypertension Other 8) CURRENT IMMUNOSUPRESSION Medication Dose / Level Medication Dose / Level Prednisone Azathioprine

Mycophenolate (MMF) Cytoxan

FK506 Leflunomide Cyclosporine Other

Sirolimus

Requesting Physician: ______Pager, cell: ______Native Kidney Biopsy Requisition Form UWMC PATIENT NO. UWMC ACCESSION NO. Anatomic Pathology, Box 356100 Room BB220D Seattle, WA 98195-6100 PATIENT NAME DATE OF BIRTH Phone: (206) 598-6400 Supplies, Fax: (206) 598-8049 AGE SEX HEIGHT WEIGHT

1) TODAY’S DATE: ______

2) PREVIOUS BIOPSY: YES / NO (If YES, date of previous biopsy: ______)

3) CLINICAL DIAGNOSIS/ CONCERNS: ______

______

4) RENAL DISEASE: - ⁪ ARF or ⁪CKD Known duration: ______

5) MEDICAL HISTORY -Hypertension YES / NO______BP: Systolic: ______/ Diastolic: ______-Diabetes YES / NO______-Family history YES / NO ______

6) TREATMENT: (If YES, please specify which drugs and dosage) Antibiotics Yes / No Antihypertensive Agents Yes / No Immunosuppressants Yes / No Other Medications Yes / No

7) LABORATORY DATA:

Creatinine _____ mg/dl SEROLOGY

Creatinine Clearance _____ml/min. ANA + / - Anti-ds DNA + / - titer ______titer ______Proteinuria ______gm/24h ANCA + / - titer ______or (circle one) 0 1+ 2+ 3+ 4+ Anti-GBM + / - titer ______Urine Culture:

RBC Complement: C3______C4______Urine WBC sediment HIV + / - HepB + / - HepC + / - casts Other ______

Requesting Physician: ______Pager, cell: ______