Table 2: Table shows Form used in laboratories to be submitted with sample.
Submitter Information | |||
Name of submitting hospital, laboratory or other facility | |||
Physician | |||
Address | |||
Phone number | |||
Case definition | O Suspected O Probable case | ||
Patients Information | |||
First Name | Last Name | ||
Patients ID number | DOB: | Age: | |
Address | Sex: | Phone number: | |
Specimen Information | |||
Type of Specimen | O Nasopharyngeal and oropharyngeal swab O Bronchoalveolar lavage O Endotracheal aspirate O Nasopharyngeal aspirate O Nasal wash O Sputum O Sputum O Serum O lung tissue O Whole blood O Stool |
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Please tick the box if sample taken is postmortem | |||
Clinical details | |||
Date of symptom onset | |||
Has patient has history of travelling to affected area | O Yes O No |
O Country: O Return date: |
|
Has the patient had contact with confirmed cases? | O Yes O No | O Unknown O Other exposure | |
Additional information |