[1]
DO NOT WRITE IN THIS
1. Last Name
First Name
MI
N.C. Department of Health and Human Services
State Laboratory of Public Health
SPACE
4312 District Drive • P.O. Box 28047
2. Patient Number
LABORATORY NUMBER
Raleigh, NC 27611-8047
4. Date of Birth
3. Address
_________________________________
...........................................................
_________________________________
Zip
Month
Day
Year
Code
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□
□
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PLEASE GIVE ALL
5. Race
1. White
2. Black
3. American Indian
4. Asian
INFORMATION REQUESTED
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□
5. Native Hawaiian/Pacifi c Islander
6. Unknown
Syphilis Serology
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□
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6. Hispanic or Latino Origin?
1. Yes
2. No
3. Unknown
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[4] Test Requested:
7. Sex
1. Male
2. Female
8. Co. of Residence
RPR (Titer and Confi rmatory
Treponema pallidum
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9. Medicaid Client
Yes
if Reactive)
confi rmatory serology
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If yes, enter #
No
—
Specimen previously tested?
RPR/TRUST result _______
[2] Federal Tax No.: _________________________________________
Specimen Source:
[5] Date Collected:
Send Report To:
x
Serum
_______________________________________________________
[6] Clinic Type:
_______________________________________________________
Family Planning
STD
_______________________________ Zip Code ________________
Prenatal
Annual Exam Date ____________
Student Health Services
Outreach
Jail/Detention Centers
Other __________
[3] Contact Name: ___________________________________________
Phone: _________________________________________________
[7] Site ID No.:
[8] Dx Code/ICD-9:
Fax: ___________________________________________________
This Section Must Be Completed
[9]
Reason for Testing:
Routine screening
Contact to a known case
Premarital, state ____________
Other ___________________________________
Prenatal
Suspicious lesion
Past history of syphilis
___________________________________
Neonatal screening
Secondary symptoms/signs
Treatment follow-up
Instructions
PURPOSE: Submission of specimens for syphilis serology (RPR and confi rmatory)
PREPARATION: Submit only serum in a plastic screw-capped vial. Clearly label each specimen with the patient’s fi rst and last name, and
either date of birth, patient number or other unique identifi er. Specimens without names or incorrectly labeled specimens will be deemed
unsatisfactory for testing. For additional information, see “SCOPE, A Guide to Services” on our website at or
contact the Virology/Serology Unit at (919) 733-7544.
PREPARATION OF FORM: Please print legibly or use a preprinted label. To avoid delays in testing, fi ll out all items in Sections 1 through 9 of
the submission form.
SHIPMENT: Send properly identifi ed specimen and completed submission form to the Laboratory as soon as possible. Additional serum
transport tubes and white-label specimen mailers for Syphilis Serology are available through the NCSLPH online supply ordering system on
our website at .
POLICY FOR LABORATORY INITIATED CONFIRMATORY TESTING BASED ON RPR RESULTS: All screening tests performed in our
laboratory which are determined to be reactive will be confi rmed, unless a previously obtained “positive” confi rmatory test result in on fi le.
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.
FOR LABORATORY USE ONLY
Unsatisfactory Specimen:
No name on specimen
Specimen broken/leaked
Other ___________________________________________________
Name on specimen/form do not match
No specimen received
Comments:
DHHS 3446 (Revised 08/15)
Laboratory (Review 08/18)