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    Icmr Specimen Referral Form For Covid-19 (Sars-Cov2) : Section A - Patient Details

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    Pcr
    This document provides instructions for filling out an ICMR specimen referral form for COVID-19 testing. It notes that the form must be completed for every sample tested and correct patient information is essential. Sections include patient details, specimen collection information, exposure history, clinical symptoms, pre-existing conditions, and hospitalization details. Fields marked with an asterisk are mandatory. The testing lab will provide the test result and details.

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    Icmr Specimen Referral Form For Covid-19 (Sars-Cov2) : Section A - Patient Details

    Uploaded by

    Pcr
    172 views2 pages
    This document provides instructions for filling out an ICMR specimen referral form for COVID-19 testing. It notes that the form must be completed for every sample tested and correct patient information is essential. Sections include patient details, specimen collection information, exposure history, clinical symptoms, pre-existing conditions, and hospitalization details. Fields marked with an asterisk are mandatory. The testing lab will provide the test result and details.

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    Covid 19 test form

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    This document provides instructions for filling out an ICMR specimen referral form for COVID-19 testing. It notes that the form must be completed for every sample tested and correct patient information is essential. Sections include patient details, specimen collection information, exposure history, clinical symptoms, pre-existing conditions, and hospitalization details. Fields marked with an asterisk are mandatory. The testing lab will provide the test result and details.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    172 views2 pages

    Icmr Specimen Referral Form For Covid-19 (Sars-Cov2) : Section A - Patient Details

    Uploaded by

    Pcr
    This document provides instructions for filling out an ICMR specimen referral form for COVID-19 testing. It notes that the form must be completed for every sample tested and correct patient information is essential. Sections include patient details, specimen collection information, exposure history, clinical symptoms, pre-existing conditions, and hospitalization details. Fields marked with an asterisk are mandatory. The testing lab will provide the test result and details.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 2

    ICMR Specimen Referral Form for COVID-19 (SARS-CoV2)

    INTRODUCTION
    This form is for collection centres/ labs to enter details of the samples being tested for Covid-19. It is mandatory to fill this form for
    each and every sample being tested. It is essential that the collection centres/ labs exercise caution to ensure that correct information
    is captured in the form.
    INSTRUCTIONS:
    ● Inform the local / district / state health authorities, especially surveillance officer for further guidance
    ● Seek guidance on requirements for the clinical specimen collection and transport from nodal officer
    ● This form may be filled in and shared with the IDSP and forwarded to a lab where testing is planned
    ● Fields marked with asterisk (*) are mandatory to be filled
    SECTION A – PATIENT DETAILS
    A.1 TEST INITIATION DETAILS
    *Doctor Prescription: Yes No *Repeat Sample: Yes No
    (If yes, attach prescription; If No, test cannot be conducted)
    If Yes, Patient ID: ………………………………………………………
    A.2 PERSONAL DETAILS

    *Patient Name: ………………………………………… *Age: …. Years/Months (If age <1 yr, pls. tick months checkbox)

    *Present Village or Town: …….…………………....… *Gender: Male Female Others

    *District of Present Residence:……………………… *Mobile Number: __ __ __ __ __ __ __

    *State of Present Residence:………………………… *Mobile Number belongs to: Self Family

    *Present patient address: ……………………………. *Nationality: …………………………………………..

    ……………………………………………………………. *Downloaded Aarogya Setu App: Yes No

    *Pincode: (These fields to be filled for all patients including foreigners)

    Email: ……………………………………………………… Passport No. (For Foreign Nationals): ……………………………..

    Aadhar No. (For Indians):

    *A.3 SPECIMEN INFORMATION FROM REFERRING AGENCY


    *Specimen type TS/NPS/NS BAL/ETA Blood in EDTA Acute sera Covalescent sera Other
    *Collection date
    *Sample ID (Label)

    *A.4 PATIENT CATEGORY (PLEASE SELECT ONLY ONE)


    Cat 1: Symptomatic international traveller in last 14 days…………………………………………………..
    Cat 2: Symptomatic contact of lab confirmed case…………………………………………………………...
    Cat 3: Symptomatic healthcare worker………………………………………………………………………..
    Cat 4: Hospitalized SARI (Severe Acute Respiratory Illness) patient……………………………………......
    Cat 5a: Asymptomatic direct and high risk contact of lab confirmed case ………………….……………...
    Cat 5b: Asymptomatic healthcare worker in contact with confirmed case without adequate protection…
    Cat 6: Symptomatic Influenza Like Illness (ILI) patient in hospital/ MoHFW identified clusters………….
    Other:……………………………………………………………………………………………………………
    (Please select “other" only if the patient doesn’t fall in any other category)
    *A.5 STATUS OF CURRENT RESPIRATORY INFECTION
    * Respiratory infection: Severe Acute Respiratory Illness (SARI): Yes No , Influenza Like Illness (ILI): Yes No

    Page 1 of 2
    SECTION B- MEDICAL INFORMATION
    B.1 EXPOSURE HISTORY(2 WEEKS BEFORE THE ONSET OF SYMPTOMS)
    1. Did you travel to foreign country in last 14 days: Yes No
    If yes, place(s) of travel: ………………………,
    2. Have you been in contact with lab confirmed COVID-19 patient: Yes No
    If yes, name of confirmed patient: ……………………………..
    3. *Were you Quarantined?: Yes No *If yes, where were you quarantined: Home Facility
    4. Are you a health care worker working in hospital involved in managing patients: Yes No
    B.2 CLINICAL SYMPTOMS AND SIGNS
    Date of onset of symptoms: …… /…… /… (dd/mm/yy) First Symptom: …………………………………
    Symptoms Yes Symptoms Yes Symptoms Yes Symptoms Yes Symptoms Yes
    Cough Diarrhoea Vomiting Fever at evaluation Abdominal pain
    Breathlessness Nausea Haemoptysis Body ache
    Sore throat Chest pain Nasal discharge Sputum

    B.3 PRE-EXISTING MEDICAL CONDITIONS


    Condition Yes Condition Yes Condition Yes Condition Yes
    Chronic lung disease Malignancy Heart disease Chronic liver disease
    Chronic renal disease Diabetes Hypertension
    Immunocompromised condition: YES NO Other underlying conditions: ………………………

    B.4 HOSPITALIZATION DETAILS


    Hospitalized: Yes No Hospital State: ………………………………………………….
    Hospital District: ……………………………………………….
    Hospitalization Date: ……… /……… / /… (dd/mm/yy) Hospital Name: …………………………………………………

    B.5 REFERRING DOCTOR DETAILS


    Doctor Mobile No.: ……………………………………………….
    *Name of Doctor: …………………………………................... Doctor Email ID: ………………………………………………….

    * Fields marked with asterisk are mandatory to be filled

    TEST RESULT (To be filled by Covid-19 testing lab facility)

    Date of sample Sample accepted/ Date of Test result Repeat Sample Sign of Authority
    receipt(dd/mm/yy) Rejected Testing (Positive / required (Yes / (Lab in charge)
    (dd/mm/yy) Negative) No)

    Page 2 of 2

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