NY-FRM-0451 - Testing Request Form - Platelet Antibody Screen / Cross-Matched Platelets - Instructions

Sep 4, 2026

Upload by Fahsai

New York Blood Center platelets testing request form for ordering a platelet antibody screen and cross-matched platelets. Provides specimen instructions including acceptable sample types, required anticoagulants, cold-chain handling, and delivery time limits. Includes sections for hospital and patient details, sample collection timing, requested test selection, compatible product type restrictions, delivery urgency (STAT/ASAP/ROUTINE), and special requirements such as CMV-negative or irradiated products. Contains QC reference use fields for receipt status and comments.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages1

Reading Time3 min

AccessFree to download

Testing Request

Platelet Antibody Screen / Cross-Matched Platelets

Form and Specimen Instructions

Hospital Information

Patient Information

Request Details

Product Delivery

QC Reference Use Only

New York Blood Center Testing Request form-Platelet Antibody Screen Cross-Matched Platelets-fillable NY-Fillable Form-rel , NY-FRM-0451, Rev: 06 Effective: 27 Aug 2025 Testing Request Platelet Antibody Screen / Cross-Matched Platelets |

Form and Specimen
Instructions
| | Fax completed form to 718-752-4756 | | | | | | | | | | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Label all specimens clearly-Last name, first name, date of birth, date drawn | | | | | | | | | | | | | | | | | | | | | | | 1 | Specimen requirements:
(2) tubes Whole Blood (no gel) or 4 mL serum/plasma.
Acceptable anti-coagulants are EDTA, ACD, CPD or CPDA-1. Samples should be transported with ICE or cold packs and MUST be less than 48 hours old when received for testing. | | | | | | | | | | | | | | | | | | | | | | 2 | For specimen pick-up: Contact Client Services Department at:
855-552-5663 or 718-707-3771 | | | | | | | | | | | | | | | | | | | | | | 3 | Send specimens with a copy of this form to:
Rye QC/Reference Laboratory, 601 Midland Ave, Rye, New York 10580 Main Phone \#: 718-752-4622 | | | | | | | | | | | | | | | | | | | |

Hospital Information

| | Hospital name: | | | | | | | | | | | | | | | Date:
| | | | | | | | Street Address: | | | | | | City: | | | | | State: | | | | | Zip:
| | | | | | | Contact Person name: | | | | | | Blood bank phone: | | | | | Fax number:
| | | | | | | | | | | | Last name: | | | | First name: | | | | DOB: | | | MRN:
| | | | | | | | | | | Patient
Information | Gender | | | Blood Type | | CMV Status | | | | | Current Platelet Count | | | | | | | | | | | | | ☐ Male | | | ABO: | | ☐ | Negative | | | | Number: | | | | | | | | | | | | | ☐ Female | | | Rh: | | ☐ | Positive | | | | Date: | | | | | | | | | | | | | | | | | | ☐ | Unknown | | | | | | | | | | | | | | | | | Diagnosis: | | | | | | | | | | | | | | | | | | | | | Sample Info | | Collection Date of Sample sent- or ☐ No Sample sent | | | | | | | | | | | | | | | | | | | | |
Request Details
| | Requested Test | | | | | Cross Matched Platelet Request
☐ Non-Type Specific acceptable
If not acceptable, complete next
columns
| | | | | | | | | Restrict to types: | | | | | | | | | ☐ Platelet Antibody Screen | | | | | | | | | | | | | | ☐ A | | | | | | | | | | | | | | | | | | | | | | | ☐ AB | | | | ☐ | Rh+ | | | | ☐ | Additional Sample for Future Testing | | | | | | | | | | | | | ☐ B | | | | ☐ | Rh- | | | | | | | | | | | | | | | | | | ☐ O | | | | | | | | Product
Delivery | ☐ STAT | | | Special
Requirements | | ☐ CMV Negative | | | | | | | | | | | | | | | | | | ☐ ASAP | | | | | ☐ Irradiated | | | | | | | | | | | | | | | | | | ☐ ROUTINE | | | | | ☐ Other (describe): | | | | | | | | | | | | | | | | Date(s) of Transfusion is required to supply product with useable expiration date: | | | | | | | | | | | | | | | | | | | | | | | Enter each date of transfusion: | | | | | | | | | | | | | | | | | | | | | | | Amount requested per transfusion: | | | | | | | | | | | | | | | | | | | | | | | QC Reference Use ONLY
Specimen Details | Received date/time: | Received by (name) : | Condition | | | | | --- | --- | --- | --- | --- | --- | --- | | | | | ☐ | Acceptable | ☐ | Unacceptable | | | Comments: | | | | | |

FAQs

What specimen types and timing are accepted for the platelet antibody screen and cross-matched platelets test?

Acceptable specimens are two tubes of whole blood (no gel) or 4 mL serum/plasma. Samples must be transported cold and must be less than 48 hours old when received for testing.

How should specimens be labeled and sent to the laboratory?

Label all specimens clearly with last name, first name, date of birth, and date drawn. Fax the completed form, then send specimens with a copy of the form to the Rye QC/Reference Laboratory address provided.

Which delivery options and special requirements can be selected for the requested platelet product?

Delivery urgency options include STAT, ASAP, and ROUTINE. Special requirements include CMV-negative and irradiated, with an additional option to describe other requirements.

Sep 4, 2026

Upload by Fahsai