REQUESTING VIRTUAL ONLINE TEST MEDIA Ø Reagents & hydrogen peroxide for catalase test DO NOT need be requested. IMPORTANT: Before Requesting Virtual Online Media: i) Fill in each test medium/media tha

Virtual Online Mixed Unknown Identification Form/Patient Chart

Unknown ‘Patient Specimen’ Identification # . (Penalty: -10 points if omitted; YOUR patient has died) ALWAYS REMEMBER: Your patient’s life is ‘in your hands.’)

Assume you are a healthcare professional. Consider this form to be your ‘patient’s chart.’ Your patient’s health or life may depend upon you always having labeled specimens correctly and recorded results accurately.

Type Name Lab Section

NOTE: Your Identification Form may vary. Point distribution will be determined by your Instructor.

REQUESTING VIRTUAL ONLINE TEST MEDIA Reagents & hydrogen peroxide for catalase test DO NOT need be requested. IMPORTANT: Before Requesting Virtual Online Media: Fill in each test medium/media that you are requesting in the correct column below Fill in each test medium/media in order starting from #1. If not performing a virtual ID due to COVID-19, before coming to the Media Bench you would normally: Complete the Test Media Requested portion of this form. Prepare all your labels. Bring a test tube rack, if you are requesting tube media. Bring these to the Media bench, where your instructor would provide you with requested test media. DO NOT TAKE MEDIA FROM MEDIA BENCH WITHOUT PERMISSION FROM YOUR INSTRUCTOR.
TEST MEDIA REQUESTED (6 Maximum for Each Organism)
15 Points	For Gram-Positive Identification	15 Points	For Gram-Negative Identification
Day 1	Columbia CNA Agar (provided free)	Day 1	Maconkey Agar (provided free)
Day 1	Trypticase Soy Agar (TSA#1) (provided free)	Day 1	Trypticase Soy Agar (TSA#1) (provided free)
	H2O2 for Catalase Test (provided free)
	#1		#1
	#2		#2
	#3		#3
	#4		#4
	#5		#5
	#6		#6

UNIQUE CHARACTERISTICS & TEST RESULTS
Points		For Gram-Positive Identification		Points	For Gram-Negative Identification
FREE	Gram Stain Reaction: Positive			FREE	Gram Stain Reaction: Negative
5	Cell Shape:			5	Cell Shape:
5	Cell Arrangement:			5	Cell Arrangement:
10	TEST		RESULT(S)	10	TEST	RESULT(S)









15	Genus & species:			15	Genus & species:
For Instructor’s Use ONLY
50	Total Points Earned			50	Total Points Earned