Form Dhhs-3390 - Enteric Bacteriology (Enterobacteriaceae) printable pdf download

1. Last Name

First Name

DO NOT WRITE IN THIS SPACE

N.C. Department of Health and Human Services

State Laboratory of Public Health

LABORATORY NUMBER

4312 District Drive • P.O. Box 28047

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

DATE RECEIVED





5. Native Hawaiian/Paciﬁ c Islander

6. Unknown

SPECIMEN TYPE:

DATE SPECIMEN COLLECTED



6. Hispanic or Latino Origin:

1. Yes

2. No

3. Unknown

 CLINICAL ISOLATED ORGANISM*

*Describe ___________________________



7. Sex

1. Male

2. Female

8. Co. of Residence

EXAMINE FOR:



9. Medicaid Client

Yes

 ENTERIC PATHOGENS

 E. COLI O157

 CAMPYLOBACTER



If yes, enter #

—

 SALMONELLA

 OTHER SHIGA-TOXIN

 YERSINIA

PRODUCING E. COLI

 SHIGELLA

Dx Code/ICD-9:

SPECIMEN SOURCE:

Federal Tax No.: _______________________________________

 STOOL

 RECTAL SWAB

Send Report To:

  BLOOD

 URINE

 WOUND–SITE ___________________

 OTHER

SYMPTOMS/EPIDEMIOLOGICAL INFORMATION

 ASYMPTOMATIC  FEVER

 CONTACT

 NURSING HOME

 BLOODY

 HEADACHE  DAY CARE

 PATIENT/CHILD CARE

DIARRHEA

 VOMITING

 FOOD HANDLER  REPEAT SPECIMEN

 CRAMPS

 NAUSEA

 FOODBORNE

 SINGLE CASE

ILLNESS

 DIARRHEA

ENTERIC BACTERIOLOGY (Enterobacteriaceae)

DHHS 3390 (Revised 08/13)

LABORATORY (Review 08/16)

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 bacteria.

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

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 Code number. Enter submitter federal tax number or social security number

in blanks. Also enter return address of submitter in box under “Send Report To.”

Right Upper Portion of Form. Examine For: Suspected disease or type examination required. Date Collected: Enter date as indicated. Specimen Type: Check

appropriate box. Specimen Source: Check appropriate box. Symptoms/Epidemiological Information: Check appropriate box(es). Provide any further information

listed at top of this page.

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 3390 (Revised 08/13)

LABORATORY (Review 08/16)