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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

(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 #

—

_____________________________________________________________

*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)

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

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