Form Dhhs 4121 - Special/atypical Bacteriology (Page 2 of 2) in pdf

PLEASE PROVIDE THE FOLLOWING CLINICAL OR EPIDEMIOLOGIC INFORMATION

ANY ASSOCIATED ILLNESS____________________________________________________

DATE OF ONSET ______________________________________

PERTINENT CLINICAL FINDINGS________________________________________________

SYMPTOMS __________________________________________

PREVIOUS LABORATORY RESULTS_____________________________________________

__________________________________________

EPIDEMIOLOGICAL DATA:  SINGLE CASE  SPORADIC  CONTACT  EPIDEMIC  CARRIER  ANIMAL CONTACT __________________

FOREIGN OR DOMESTIC TRAVEL? WHERE? _____________________________ WHEN? (WITHIN LAST YEAR ) ________________________________

OTHER ____________________________________________________________________________________________________________________________

INSTRUCTIONS

PURPOSE: Isolation, identiﬁ cation, conﬁ rmation, further studies of human disease-producing aerobic bacteria.

PREPARATION: Collect specimen following instructions in SCOPE, using recommended collection kits. Label each specimen tube, subculture, or

smear with patient's name and date of birth. Fill out this form and send in appropriate mailer with the specimen to State Laboratory of Public Health.

Place form in outer container. Do not send without label (patient name) on specimen or without form. Forms must be printed from website at http://

PREPARATION OF FORM: Left Upper Portion of Form. Item 1. Enter patient's name, last name ﬁ rst, ﬁ rst name, and middle initial or maiden name

initial, if female. Item 2. Enter patient number (SSN or other unique number). Item 3. Enter patient's home address on lines immediately below. This

information is required for epidemiologic follow-up. Item 4. Enter date of birth (not age). Items 5, 6, and 7. Indicate race, Hispanic ethnicity, and sex

by checking appropriate box. These data are for statistical purposes only. Item 8. Enter county of residence of patient (Health Departments use county

code). Item 9. Indicate if patient is a Medicaid client; if yes, enter Medicaid number. Enter Diagnosis Code or ICD-9 number. Enter submitter federal

tax number or social security number in blank. ALSO ENTER RETURN ADDRESS OF SUBMITTER in box under “Send Report To.”

Right Upper Portion of Form. Specimen Type: Check appropriate box. Date Specimen Collected: Enter date as indicated. Examine For: Suspected

disease or type examination required. Specimen Source: Check appropriate box. Symptoms/Epidemiological Information: Check appropriate box(es).

Provide any further information listed at top of this page.

Do not write in space below “Laboratory Report.”

DISPOSITION: This form may be destroyed in accordance with Standard 5, Patient Clinical Records, of the Records Disposition Schedule published

by the N.C. Division of Archives and History.

DHHS 4121 (Revised 10/13)

LABORATORY (Review 10/16)

Form Dhhs 4121 - Special/atypical Bacteriology Page 2

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