Free Virologg (07-29-2008) (27408 - - Indiana

VIROLOGY
State Form 35212 (R5/7-08)

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CLIA Certified Laboratory #15D0662599

Indiana State Department of Health Laboratories 550 W. 16th Street, Suite B Indianapolis, IN 46202 (317) 921-5500

Use a separate form for each specimen.

Specimens without a name will not be analyzed.

Section 1. Patient Demographics

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Last Name First Name MI Number & Street Address City State

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ZIP Code

Date of Birth

Race:
County of Residence White Multiracial Other Unknown Asian Black or African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander

Phone Number Not Hispanic or Latino Unknown Unknown

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Ethnicity:
Hispanic or Latino

Sex:
Male Female

Name of Employer Institution Resident ? School No Yes Care Facility Institution Prison Institution Type

Occupation

Facility Phone Number Nursing Home Other (specify)

Address of Employer/School/Care Facility/Institution

City

State

ZIP Code

Section 2. Clinical Information
Specimen Information: Isolate Swab Stool
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Anatomical Site Is Patient Immunocompromised? Yes No

Date of Illness Onset

Date of Collection

Clinical Diagnosis State of Illness Asymptomatic CNS Encephalitis
Meningitis Ocular Conjunctivitis Photophobia

Symptomatic (If patient is symptomatic, please check all signs/symptoms that apply) Exanthema Maculopapular
Papular Hemorrhagic Vesicular Petechial

General Symptoms Fever
Headache Cough
°F

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Respiratory Upper Resp. Inf.
Lower Resp. Inf. Pneumonia ARDS

Gastrointestinal Vomiting
Diarrhea

Sore Throat

Cardiovascular Heart Inflammation

Other Symptoms (please specify) Is this specimen part of a public health investigation?
Yes No Unknown

Section 3. Influenza Submission Information

Influenza Authorization Code Influenza Rapid Test:
Positive Negative

Influenza Sentinel Physician #
Not Performed Killed Vaccine No

If positive:

Type A

Type B

Type A/B

Not Typed 1 2

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Vaccination Date
Yes

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Vaccine Type

Attenuated Vaccine/Flu Mist

Number of Doses:

Patient Received/Receiving Antivirals? Which antiviral prescribed?

If Yes, Date Administered

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Patient Contact with (check all that apply) :

Birds

Animals

Family

Community

Resp. Disease Outbreak

Complete Reverse Side

VIROLOGY
State Form State Form 35212 (R5/7-08)

Section 4. Travel History
Travel history for the past 60 days: Traveled to/from:

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Adenovirus Enterovirus

Date of Departure

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Date of Return

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Section 5. Virus Suspected
Norovirus Parainfluenza Respiratory Syncytial Virus Varicella Community-Acquired Pneumonia Other

Herpes Simplex Influenza Measles Mumps

Section 6. Submitter Information

Healthcare Provider's Name

E-Mail Address

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Phone Number

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Fax Number

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Submitting Facility Name Number & Street Address City State ZIP Code

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Phone Number

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Fax Number

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Collect specimen for virus culture and PCR testing as early as possible in the acute stage of illness. Acceptable specimens may include the following: isolates, NP swabs or throat swabs, stools or rectal swabs, body fluids, lesion swabs or scrapings, biopsy tissue (no preservative), and postmortem tissues (no preservative) depending on the suspected virus. Swabs must be placed in 2-3 mL of viral transport media such as M4, M4-RT, M5 UTM-RT, etc. Use a 7A container, available from the ISDH Container Section, for Norovirus specimens. Refrigerate specimens for virus culture and PCR testing immediately after collection at 2-8° C. Wrap the labeled specimen container with absorbent material and place in a biohazard specimen bag to prevent breakage or spillage during shipment. Ship specimens within 24 hours in a heavily insulated box with sufficient ice packs to maintain 2-8° C while in transit. Pack specimens to prevent breakage or spillage. Ship the box compliant with DOT and IATA regulations. Viral recovery may be complicated if specimens are not shipped refrigerated immediately after collection If shipment and delivery to the ISDH laboratories is not possible within 24 hours after collection, specimens must be frozen at -70° C or below. Do not store at -20° C. Ship frozen specimens on 10 lb. dry ice in a heavily insulated box. Do not ship on Friday, hold in freezer for Monday shipping. Specimens should be be received by the ISDH Laboratory within 5 days of collection.

For ISDH Lab. Use ONLY

Place Label here

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Date Received

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