Form Dhhs 5010 - Bt And Emerging Pathogens - N.c. Department Of Health And Human Services

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1. Last Name
First Name
MI
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
(Soc. Security No.)
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/Pacific Islander 
6. Unknown
DATE SPECIMEN COLLECTED:
6. Hispanic or Latino Origin:
1. Yes
2. No
3. Unknown
SPECIMEN TYPE:
 ISoLatED orGaNISM*
7. Sex
1. Male
2. Female
8. Co. of Residence
 SMEar
 CLINICaL**
9. Medicaid Client
Yes
EXaMINE For: ________________________________________________
If yes, enter #
No
_____________________________________________________________
*Describe organism _____________________________________________
Federal Tax No.: _______________________________________________
_____________________________________________________________
Send Report To:
_____________________________________________________________
SPECIMEN SOURCE:
 bLooD  CSF  UrINE  SPUtUM  NP  StooL
 WOUND-SITE  otHEr ____________________________________
BT and Emerging Pathogens
Contact Name: _________________________________________________
Phone: _______________________________________________________
SPECIMEN UNSATISFACTORY:
Fax: _________________________________________________________
 broKEN/LEaKED IN traNSIt
 SPECIMEN UNLabELED
Ordering Physician: _____________________________________________
 QUaNtIty INSUFFICIENt
 SPECIMEN IMProPErLy PrEParED
Ordering Physician's Phone: ______________________________________
 No SPECIMEN
 ForM IMProPErLy PrEParED
**PROVIDE THE FOLLOWING CLINICAL AND/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, identification, confirmation and/or further studies of suspected agents of bioterrorism or emerging pathogens.
PREPARATION: PRIOR TO SUBMISSION, call 919-807-8600 for guidance on collection (information can be found in SCOPE), transport
of samples and package labeling. Label each specimen tube, subculture or smear with patient's name and social security number or date of
birth. Complete this form and submit with the specimen following current shipping guidelines. Place form in outer container.
Do not send specimen without labeling or submit without completed form. Forms are available at
default.asp#subform.
PREPARATION OF FORM:
Left upper portion of Form: Item 1: Enter patient's name, last name first and middle initial or maiden name initial, if female. Item 2: Enter
patient's social security number. This is the identifying number for that patient. If the patient has no social security number, please indicate
on form. 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, 7: Indicate race, Hispanic ethnicity and sex by checking the appropriate box. These data are for
statistical purposes only. Item 8: Enter County of residence of patient. Item 9: Indicate if patient is a Medicaid client; if yes, enter Medicaid
number. Enter Submitter federal tax identification number in the space provided. Enter the return address of the submitter in the "Send
Report To" area. Provide contact name, telephone and fax number of individual responsible for the specimen. Enter the name and contact
information of the ordering physician.
Right Upper Portion of Form: Enter date specimen collected. Specimen Type: Check appropriate box. Examine For: Enter suspected
organism or type of examination required. Describe organism if from an isolated organism. Specimen Source: Check appropriate box.
Middle Portion of Form: Symptoms/Epidemiological Information: Provide any further clinical and/or epidemiological information if testing is for
a clinical sample. Check appropriate box(es).
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 5010 (03/13)
Laboratory (review 03/16)

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