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Vrdl General Purpose Laboratory Submittal Form - California Department Of Public Health Page 2

Sample Type and Shipping Instructions

Transport of original specimens:

• Submit ~0.75ml of the original specimen.

• Ideally ship frozen on dry ice.

• An overnight shipment at 4C (cold packs) can be done as alternative.

Additional Space for Unusual Clinical Findings, Travel History and Risk Factors

______________________________________________________________________________

Supplemental Questions:

1) Did patient travel within the last 10 days before onset of symptoms?

[ ] Yes

[ ] No

If YES, where?

_________________________________________________________________________________

___________________________________________________________________________

2) Did patient become infected in an outbreak setting*?

[ ] Yes

[ ] No

If YES, name of location/setting?

_________________________________________________________________________________

___________________________________________________________________________

3) Did patient receive seasonal influenza vaccination ≥ 14 days prior to onset of symptoms?

[ ] Yes [ ] No

If yes, how many doses? __________________________

4) Is patient taking antiviral drugs?

[ ] Yes

[ ] No

If YES, what drug?

________________________________ and date started ____/____/____

Vrdl General Purpose Laboratory Submittal Form - California Department Of Public Health Page 2