Specimens Collected During The Physical Exam (Hiv) Page 2
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1
2WIHS ID #
PROMPT:
IF PARTICIPANT PROVIDED A HAIR SPECIMEN, COMPLETE FORM F31a (HAIR
COLOR, TEXTURE, AND TREATMENT HISTORY).
SECTION C. GYN SPECIMENS
C1.
a. WERE ANY GYN SPECIMENS COLLECTED?
YES ................................................................. 1 (b)
NO ................................................................... 2
IF NO, SPECIFY REASON: ____________________________________ (END)
b. DATE GYN SPECIMENS COLLECTED:
/
/
M
D
Y
SPECIMEN TYPE
LAB
YES
NO
IF NO, SPECIFY REASON
N/A
C2. Minimum 6 ml CVL Fluid
Local for
1 (a)
2
_________________ (C3)
Aliquoting and
Freezing
a.) IF YES, time of collection:
|__|__| : |__|__|
AM……..1
PM……..2
C3. Slide for Bacterial Vaginosis
Central
1 (C4)
2
______________________
Gram Stain
C4. 1 Glass Slide for Pap Smear
Central
1 (C5)
2
______________________
C5. 1 Cervical swab for HPV DNA Central
1 (C6)
2
__________________
C6. Optional: Swab in Diamonds
Exam Site
1 (END)
2
______________________
3
Media for Trichomonas
Culture
WIHS Form 31: Specimen Collection – 10/01/10
Page 2 of 2
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