Form Dhhs-1188 - Rubella Serology
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1DO NOT WRITE IN THIS
[1]
N.C. Department of Health and Human Services
1. Last Name
First Name
MI
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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5. Race
1. White
2. Black
3. American Indian
4. Asian
PLEASE GIVE ALL
□
□
INFORMATION REQUESTED
5. Native Hawaiian/Pacifi c Islander
6. Unknown
□
□
□
6. Hispanic or Latino Origin?
1. Yes
2. No
3. Unknown
Rubella Serology
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7. Sex
1. Male
2. Female
8. Co. of Residence
□
Test Requested:
Specimen Source:
9. Medicaid Client
Yes
□
X
X
If yes, enter #
No
—
Rubella igG Antibody
Serum
[4] Date Collected
[2] Federal Tax No.: ________________________________________
Send Report To:
______________________________________________________
[5] Clinic Type: Prenatal
______________________________________________________
Family Planning
Annual Exam Date ______________________
_______________________________ Zip Code _______________
Other _________________________________
[6] Site ID No.:
[7] Dx Code/ICD-9:
[3] Contact Name: _________________________________________
Phone: ________________________________________________
Fax: __________________________________________________
This Section Must Be Completed
[8]
Reason for Testing:
Referral Specimen Information:
Prenatal patient
Previous serum collection date ___________________________________
Vaccine contraindicated
Previous rubella test method _____________________________________
Other ____________________________________________________
Previous rubella result __________________________________________
Instructions
PURPOSE: Submission of specimens for immune status rubella antibody (IgG)
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 8 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 blue-label specimen mailers for Special Serology are available through the NCSLPH online supply ordering system on our
website at .
TESTING SHOULD NOT BE DONE ON PATIENTS WHO HAVE A VERIFIED RECORD OF RUBELLA IMMUNIZATION. (NOTE: RUBELLA
VACCINE WAS NOT LICENSED FOR SALE UNTIL JUNE 9, 1969.)
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 1188 (Revised 11/13)
Laboratory (Review 11/16)
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