Free 53761.pdf - Indiana

OUTBREAK SEROLOGY REQUEST
State Form 53761 (11-08)

CLIA Certified Laboratory #15D0662599

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INDIANA STATE DEPARTMENT OF HEALTH LABORATORIES TH 550 W. 16 STREET, SUITE B INDIANAPOLIS, IN 46202

SECTION 1. PATIENT DEMOGRAPHICS_________________________________________________________________ ____________________________________ _______________________________ ________ _______/______/______
Last Name First Name MI Date of Birth

___________________________________
Patient ID

____________________________________ __________ _____________
City / County of Residence State ZIP Code

Race:

Ethnicity:

Asian Black or African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander
Name of

White Multiracial Other Unknown

Hispanic or Latino Unknown
Sex:

Not Hispanic or Latino Unknown
_____________________
Occupation

Male

Female

________________________________________________

_____ - _____ - ___________
Facility Phone Number

Employer School Care Facility Institution
Staff?

Institution Resident? Yes

No Yes No

Institution Type Prison Nursing Home Other (specify)

______________________________

SECTION 2. SPECIMEN INFORMATION__________________________________________________________________

Blood Serum CSF

Date of onset ____/____/____

Date collected: Acute____/____/______ Is patient immunocompromised?

Convalescent____/____/_____

Is specimen part of a public health investigation?

Yes No Unknown

Yes No

SECTION 3. TEST SELECTION______________________________________________________f_______________ ___
Agent suspected_______________________________________________________________________________________

Hepatitis A Measles IgM Measles IgG Rubella IgM Rubella IgG

Mumps IgM Mumps IgG Varicella IgM Varicella IgG Legionella

Hantavirus Coxiella (Q-fever) Ehrlichia Rickettsia (RMSF and Typhus fever) Arbovirus Panel (WNV, SLE, EEE, WEE, CE)

West Nile Virus Lacrosse Encephalitis St. Louis Encephalitis

SECTION 4. SYMPTOMS_________________________________________________________________________ _____

Symptomatic Asymptomatic Chronic Localized Disseminated
General Symptoms Exanthema CNS Respiratory G.I.

Fever ______°F Headache Sore Throat Cough Myalgia Anorexia Otitis Parotitis
Ocular

Maculopapular Papular Hemorrhagic Vesicular Petechial Erythema Migrans Oral Lesion Genital Lesion
Cardiovascular

Encephalitis Meningitis Neck Rigidity Seizures Paralysis Chorea

Common Cold ARDS Upper Resp. Inf. Lower Resp. Inf. Pneumonia Bronchitis Pharyngitis
Miscellaneous

Nausea Vomiting Diarrhea Abdominal Pain Constipation Gastroenteritis

Organomegaly

Other
______________________ ______________________ ______________________ ______________________

Conjunctivitis Chorioretinitis Blurred Vision

Myocarditis Pericarditis Endocarditis Cardiomegaly

Splenomegaly Hepatomegaly Orchitis

Jaundice Lymphadenopathy Pleurodynia

SECTION 5. CONTACT / EXPOSURE________ ___________________________________________________________

Contact with and/or Exposure to: Human Cases Insects Animals Birds Similar Infection: Family Yes No Community Yes No
COMPLETE REVERSE SIDE

SECTION 6. TRAVEL HISTORY_____ Travel history for the past 60 days:____________________________________________
Traveled to / from ___________________________________________________________________________________________________________ Date of Departure_______/_______/_________ Date of Return________/________/_________

SECTION 7. RELATED IMMUNIZATIONS _____________
1. 2. 3.

_RECENT VACCINATIONS____

___________________

__________________________________ Date______/______/______ 1. __________________________________ Date______/______/______ __________________________________ Date______/______/______ 2. __________________________________ Date______/______/______ __________________________________ Date______/______/______ 3. __________________________________ Date______/______/______

SECTION 8. PROVIDER INFORMATION_ ________________________________________________________________

_________________________________________________________________________________
Healthcare Provider's Name

__________________________________________ _____-_____-________ _____-_____-______
E-mail Address Phone Number Fax Number

SECTION 9. SUBMITTER INFORMATION_________________________________________________________________ ______________________________________________________________ ____________________________________
Submitting Organization Phone Address Fax Staff Name E-mail

__________________________ _________________________ ____________________________ _________________________________________________________________________________ _________________________________________________________________________________
Address

________________________________
City

_________________________ _____________________
State ZIP Code

SPECIMEN COLLECTION

___________________________________________________________________

Submit at least 1ml of serum in a screw-capped serum tube. Alternatively collect at least 3ml for whole blood in a red top venipuncture or serum separator tube. Label the specimen tube with patient identifier and collection date. Specimens without a patient ID or collection date will be considered unsatisfactory and will not be tested. Complete all sections 1 through 9 on this form in ink. Patient ID and collection date must match those recorded on the specimen tube. The submitter address to which the results are to be sent including zip code must be included as well as requested test type. Any incomplete information will cause significant delays in receiving results.

SPECIMEN PACKAGING AND SHIPMENT________________________________________________________________
Note: Specimens should be refrigerated at 4°C if held prior to shipping. Serum or whole blood in serum separator tubes may be shipped at ambient temperature. Shipping whole blood in red top tubes at ambient temperature may result in hemolysis and a specimen unsatisfactory for testing. 1. 2. Use container 9A provided by ISDH. ISDH containers may be obtained by phoning (317) 921-5875. Wrap the absorbent material, provided in the inner mailing container, around the specimen tube to absorb inner shock and contain possible leakage. Insert the wrapped specimen tube into the inner mailing container. Secure cap tightly. Place the completed requisition between the inner and outer mailing container and secure cap. Specimens should be shipped to arrive at ISDH Monday through Friday. Shipping specimens which will be in transit during the weekend or holiday is not recommended. Complete the pre-addressed mailing label on the outer mailing container with a return address, leakage and breakage notification and postage, and send via first class US mail. Please use the above packing instructions to assure compliance with federal shipping regulations and to minimize breakage. Broken or leaking specimens present a biohazard and cannot be tested. Specimens submitted by courier should be packaged securely to prevent breakage. Loose specimens in zip lock bags increase the chance of breakage and biohazard exposure.

3. 4. 5.

DIRECT QUESTIONS TO: 317-921-5858

ISDH Lab Use Only Date Received_________________________________

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