Form Dhhs 3722 - Hepatitis Serology
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1
2N.C. Department of Health and Human Services
DO NOT WRITE IN THIS
[1]
1. Last Name
First Name
MI
State Laboratory of Public Health
SPACE
4312 District Drive • P.O. Box 28047
LABORATORY NUMBER
2. Patient Number
Raleigh, NC 27611-8047
4. Date of Birth
3. Address
________________________________
..............................................................
________________________________
Zip
Month
Day
Year
Code
PLEASE GIVE ALL
5. Race
1. White
2. Black
3. American Indian
4. Asian
INFORMATION REQUESTED
5. Native Hawaiian/Pacifi c Islander
6. Unknown
6. Hispanic or Latino Origin?
1. Yes
2. No
3. Unknown
HEPATITIS SEROLOGY
7. Sex
1. Male
2. Female
8. Co. of Residence
[3] Date Collected:
[4] Date of Onset:
9. Medicaid Client
Yes
If yes, enter #
No
—
[2] Federal Tax No.: _______________________________________
[5] Site ID No.:
[6] Dx Code/ICD-9:
Send Report To:
____________________________________________________________________
[7] Contact Name: ______________________________________
____________________________________________________________________
Phone: ____________________________________________
________________________________________Zip Code: ____________________
Fax: ______________________________________________
[8] Test Panel(s) Requested:
Hepatitis B Virus (HBV) Screen
Hepatitis Diagnostic
Reason for testing (Must check all that apply to your patient):
Reason for testing (Must check all that apply to your patient):
Hepatitis B Virus (HBV)
Prenatal patient
Symptomatic (recent or current)
Estimated Date of Confi nement (EDC) __ __/__ __/__ __
Hepatitis A Virus (HAV)
Refugee
Symptomatic without an epidemiologic link to another case
Sexual or needlesharing contact of known infected person
known to be infected with Hepatitis A
Confi rmation of suspected cases, whether or not epidemio-
Household contact of chronic HBV carrier (or acute cases)
logically-linked, if: (please indicate)
who is at high risk of HBV exposure and who is a candidate
foodhandler
for HBV vaccine
health care worker
Other, explain (prior approval required)*
daycare attendee
____________________________________________
daycare worker
____________________________________________
at risk for other causes of liver disease
(i.e., reports IV drug use, alcohol abuse, other)
Source patient from whom exposure occurred
Hepatitis B Virus (HBV) Monitor
Hepatitis A Virus (HAV) Outbreak
Reason for testing (Must check all that apply to your patient):
Reason for testing (Must check all that apply to your patient):
Outbreak situation (prior approval required)*
Follow-up of infant (12-15 months old) born to infected
mother
Other, explain (prior approval required)*
_________________________________________
Follow-up of person with previous positive test for HBsAg or
_________________________________________
history of Hepatitis B infection
_________________________________________
_________________________________________
Previously vaccinated health department employee with
_________________________________________
percutaneous exposure to Hepatitis B
FOR LABORATORY USE ONLY
Unsatisfactory Specimen:
No name on specimen
Specimen broken/leaked
Other ____________________________________
Name on specimen/form do not match
No specimen received
*SEE REVERSE SIDE FOR INSTRUCTIONS AND FURTHER INFORMATION
DHHS 3722 (Revised 08/13)
Laboratory (Review 08/16)
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