Mumps Virus Specimen Collection Form
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1
2California Department Health Services
April 21, 2010
Viral and Rickettsial Disease Laboratory
Mumps Virus Specimen Collection Form
Last Name: ______________________ First Name:
DOB: ____/____/____ Medical Rec #:____________
_
Address: ________________________________________ City: __________________________ Zip Code: _____________
Phone: Home (______)________________ Work (______)________________
Sex:
Male
Female
Ethnicity:
Hispanic
Non-Hispanic
Unknown
Race:
White
Black
Asian/ Pacific Islander
American Indian/Alaskan Native
Unknown
Other: ________
Physician Information:
Name: __________________________ Facility: ________________________________ Pager/Phone: (______)__________
Date of first symptom(s):____/____/____
Hospitalized or
ER / Outpatient
If hospitalized, admit date: ____/____/____ Discharge date: ____/____/____ If patient died, date of death: ____/____/____
Clinical syndrome:
History of clinical mumps
Swelling of parotid gland
Yes
No
Unk
(prior to current illness):
Yes
No
Unk
____/____/____
If yes, give date of onset of parotid swelling:
Vaccination History:
Swelling of sublingual or
Yes
No
Unk
# of doses (lifetime) of mumps containing vaccine received: _____
submaxillary glands
Vaccination Dates (if known):
___/___/____
___/___/____
___/___/____
Fever
Yes
No
Unk
Reason if not vaccinated: _______________________________
URI symptoms (e.g.
Yes
No
Unk
cough, sore throat)
_____________________________________________________
Asymptomatic
Yes
No
Unk
Exposures/Travel within 4 wks of onset (specify details):
Other, please describe
Traveled outside of California:
Yes
No
Unk
_______________________________________________
If yes, where:__________________________________________
Complications
(e.g, orchitis, meningitis/encephalitis):
Contacts/exposures: ____________________________________
_______________________________________________
_
Route to:
Disease suspected or test requested:
This section for Virus Laboratory use only.
Date received by VRDL and State Accession Number
[ ] SERO
[ ] ISOL
Specimen type and/or specimen source
Date Collected
[ ] FA
st
1
[ ] RAB
st
1
[ ] EM
Specimen type and/or specimen source
Date Collected
[ ] BE
nd
nd
[ ] LC
2
2
[ ] _____
[ ] _____
Specimen type and/or specimen source
Date Collected
[ ] _____
rd
rd
3
3
[ ] _____
[ ] E IgM
David Schnurr, Ph.D., Acting Chief
Submitter’s Complete Mailing Address
[ ] E PCR
Viral and Rickettsial Disease Laboratory
[ ] H PCR
Division of Communicable Diseases
[ ] C PCR
California Department of Health Services
[ ] _____
850 Marina Bay Parkway
code:
Richmond, CA 94804
phone (510) 307-8585 fax (510) 307-8599
FAX this form: (510) 307-8599 or MAIL to: CDHS VRDL, 850 Marina Bay Parkway, Richmond CA 94804
For questions regarding testing or specimens, call VRDL at 510.307.8585
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