Form Dhhs 3431 - Virology printable pdf download

N.C. Department of Health and Human Services

[1]

DO NOT WRITE IN THIS

1. Last Name

First Name

State Laboratory of Public Health

SPACE

4312 District Drive • P.O. Box 28047

2. Patient Number

Raleigh, NC 27611-8047

LABORATORY NUMBER

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



VIROLOGY

6. Hispanic or Latino Origin?

1. Yes

2. No

3. Unknown



7. Sex

1. Male

2. Female

8. Co. of Residence



[4] INFECTIOUS AGENT(S) SUSPECTED OR TEST(S) REQUIRED:

9. Medicaid Client

Yes

—



 Comprehensive Viral Culture  Inﬂ uenza  Mumps

If yes, enter #

 HSV/VZV  Other _______________________________

[2] FEDERAL TAX NO. ______________________________________

[5]

[6]

[7]

SPECIMEN SOURCE

DATE COLLECTED

CLINIC

SEND REPORT TO:

_____ Prenatal

______________________________________________________

(a)

(Due Date: _________)

______________________________________________________

(b)

_____ STD

__________________________________ Zip Code: ___________

_____ OTHER

(c)

[3] Contact Name: _________________________________________

[8] ONSET DATE:

[9] Dx Code/ICD-10:

Phone: ________________________________________________

Fax: __________________________________________________

[10] PATIENT SIGNS AND SYMPTOMS

Patient Expired?  Yes

Date: _______________________________________________

GENITAL

RASH

RESPIRATORY

CNS

CARDIOVASCULAR

GENERAL

 Vesicles

 Seizures

 Chest Pain

 Fever to _____ °

 Macular

 Cough

 PID

 Meningitis

 Pericarditis

 Headache

 Papular

 Pneumonia

 Cervicitis

 Encephalitis

 Myocarditis

 Fatigue

 Vesicular

 Bronchitis

 Urethritis

 Nuchal rigidity

 Pleurodynia

 Sore Throat

 Croup

 Petechial

 Hysterectomy

 Paralysis

GASTROINTESTINAL

 Jaundice

 Pharyngitis

 Focal

 Mucopurulent discharge

 Nausea/vomiting

 Conjunctivitis

 Hemorrhagic

 Atypical Lesion

 Diarrhea

Travel History:

Recent Vaccination History:

Instructions

PURPOSE: Submission of specimens for detection of viral infectious agents by viral culture and/or molecular diagnostics.

PREPARATION: Clearly label each specimen primary container with the patient’s ﬁ rst and last name, either date of birth, patient number or other

unique identiﬁ er, specimen source and collection date. Specimens without names or incorrectly labeled specimens will be deemed unsatisfactory for

testing. Submit no more than three specimens per patient with each form. 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 10 of the

submission form. Enclose submission form in a plastic bag to prevent contamination due to possible leakage.

SHIPMENT: Keep properly identiﬁ ed specimens cold BUT NOT FROZEN (cold packs and leak-proof Styrofoam container) and deliver to the

Laboratory within 48 hours of collection. Specimens for CMV or RSV culture should be refrigerated immediately after collection and delivered to the

Laboratory within 24 hours. Additional specimen collection and transport kits are available through the NCSLPH online supply ordering system on our

website at

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:

INTERPRETATION:

 No name on specimen

 Specimen broken/leaked

 Other _______________________

 Negative: No virus detected.

 Name on specimen/form do not match

 Collected in incorrect transport media

 Virus detected using

molecular assay.

TEMPERATURE ON ARRIVAL:  FROZEN

DATE RECEIVED

 COLD

 AMBIENT

 Virus detected using DFA

Comments:

Results telephoned

method.

 Four or more days

 Other __________________________________

to ___________________________

 Viral-like agent detected.

between collection and

Further testing in process.

receipt of specimen

_______________________________________

date _________________________

 Positive virus identiﬁ ed as:

 Specimen broken or leaked

in transit

_______________________________________

by ___________________________

 Specimen received

ambient

DHHS 3431 (Revised 04/2016)

Laboratory (Review 04/2019)

Form Dhhs 3431 - Virology

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