OUTBREAK SEROLOGY REQUEST
State Form 53761 (11-08)
CLIA Certified Laboratory #15D0662599
Reset Form
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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