Zika Virus Testing Authorization Request
ADVERTISEMENT
1Zika Virus Testing Authorization Request
Completed form should be sent by fax to: Chicago Department of Public Health Communicable Disease program: fax 312-746-4683.
Submitting lab should include both CDC-DASH form and IDPH test requisition with approval number once provided by CDPH. Provider should
complete clinical information on form 50-34; the lab will complete the submitter information and IDPH test requisition.
CDC links:
Today’s Date: ___________________
Form Completed by Name: ____________________________ Phone: ____________________ Email: _______________________________
Patient FName: ____________________________ LName: ____________________________ Phone: ____________________
Address: _______________________________ Chicago Resident :
Y
N DOB: ____________________ Age: ___________ Sex:
M
F
Provider FName: ____________________________ LName: ____________________________ Facility: ____________________
Phone: ____________________ Email: ____________________
Date of symptom onset: _______________________ Symptoms (mark all that apply):
Rash
If Yes,
Maculopapular
Patechial
Purpuric
Other: ______________________
Fever; Recorded Temp:_______
Joint pain
Conjunctivitis
Myalgia
Other: __________________________________________________________
Asymptomatic
Travel History for patient returning from an
area with known Zika virus
transmission:
Country visited: _______________________________
Departure Date: ____________ Return Date: _______________________________
Country visited: _______________________________
Departure Date: ____________ Return Date: _______________________________
History of living in a
dengue-endemic
area? If Yes, countries: _______________ Approximate Date: ____________
Prior Diagnosis of Chikungunya:
Y
N
Approximate Date: ____________
Prior Diagnosis of Dengue Fever :
Y
N
Approximate Date: ____________
History of receiving yellow fever or Japanese encephalitis vaccine? :
Y
N
Is the patient pregnant?
Yes
No
If Yes,
a. Approximate gestation/trimester when she traveled ____(week) and became ill ___(week)
b. Date of last ultrasound:____________________ If, not performed, date scheduled:____________________
c. Ultrasound findings:
Normal
Brain Calcification
Microcephaly
Other: __________________
Additional tests ordered (and results if available) for other etiologies:_________________________________________________
__________________________________________________________________________________________________________
Comments:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Zika Virus testing (mark all that apply)
Date Collected
Specimen Source:
Specimen ID
For CDPH only:
Identifying number
Authorization Number (ZIKCDPH###)
I-NEDSS
CDPH,
February 8, 2016
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical