Zika Virus Testing And Report Form
Download a blank fillable Zika Virus Testing And Report Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Zika Virus Testing And Report Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6ZIKA VIRUS TESTING AND REPORT FORM
FAILURE TO COMPLETE REQUIRED FIELDS WILL RESULT IN
SPECIMEN REJECTION OR DELAYED TESTING
Acute Communicable Disease Control
313 N. Figueroa St., Rm. 212
Los Angeles, CA 90012
213-240-7941 (phone), 213-482-4856 (fax)
publichealth.lacounty.gov/acd/
Date of Request
REQUIRED SUBMITTER INFORMATION
Requesting Physician Name (Last, First)
Facility/Submitter Name and Address
Requesting Physician Pager or Phone No.
Facility Fax Number
Facility Phone Number
Contact Person for Specimen(s)
Requesting Physician Email
Contact Person Phone
REQUIRED EPIDEMIOLOGICAL INFORMATION
The patient:
1. Resides in
Los Angeles County
?
Yes
No
If No, Call appropriate HEALTH DEPARTMENT.
(click hyperlink to lookup address)
2. Has a history of travel to a
Zika affected country
?
Yes
No
(click hyperlink for list)
If Yes, Country? ___________________________
Dates of travel: From ____________ to ____________
3. Is what gender?
Male
Female
Other: ______
If Female, Pregnant?
Yes
No
If Yes, Estimated date of delivery: _______________
Ultrasound screening evidence of microcephaly &/or calcifications in a fetus?
Yes
No
Not done
Did the pregnant woman have unprotected sex with a male traveler who had symptoms w/in 14 days of his return?
Yes
No
If Yes, Male Partner Name _____________________________
Complete another testing form for symptomatic male.
4. Has any of the following symptoms?
Yes
No
If Yes, Specify symptoms and Onset Date: _________________
Acute onset of fever (measured or reported)
Maculopapular rash
Arthralgia
Conjunctivitis
5. Is a postpartum mother who has an infant with evidence of microcephaly?
Yes
No Delivery date: _____________
6. Has a Guillain-Barré Syndrome diagnosis?
Yes
No
If Yes, Specify Onset Date: ____________
REQUIRED ELIGIBILITY SCREEN FOR TESTING
Using the Epidemiological Information section above, check which category the travelers fits in:
Symptomatic Pregnant Traveler
Onset of symptoms within 14 days of return OR
Onset during travel
Asymptomatic Pregnant Traveler - Within 12 weeks after return from travel
Pregnant Traveler – regardless of symptoms
Ultrasound screening evidence of microcephaly and/or calcifications in a fetus
OR
Fetal loss
Infant of a Recently Pregnant Traveler - Evidence of microcephaly in an infant
Provide Mother’s Name ________________________________ and Mother’s Date of Birth ____________________
Infant with no apparent defect AND the mother has laboratory evidence of Zika virus infection (See instructions.)
Symptomatic pregnant woman with NO travel history AND had unprotected sex with a symptomatic male traveler
Symptomatic Non-Pregnant Traveler (Male or Female) - Onset of symptoms within 14 days of return
Traveler with a Guillain-Barré Syndrome diagnosis
Patient does not fit into any of the above categories.
Contact Acute Communicable Disease Control at 213-240-7941 for consultation.
Patient Name (Last, First, Middle Initial)
Date of Birth
(mm/dd/yyyy)
ZIKA VIRUS TESTING AND REPORT FORM AND INSTRUCTIONS - ZikaInfoTestReq (6/23/16)
Page 1 of 6
CONFIDENTIAL – This material is subject to the Official Information Privilege Act
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business