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    Icmr Specimen Referral Form For Covid-19 (Sars-Cov2) : (If Yes, Attach Prescription If No, Test Cannot Be Conducted)

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    udayan
    This document is an ICMR specimen referral form used to collect details of COVID-19 samples being tested. It requires information on the patient, doctor, specimen, symptoms, medical history and test results. Fields marked with an asterisk are mandatory. The form provides instructions to contact local health authorities for guidance on clinical specimen collection and transport.

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    Icmr Specimen Referral Form For Covid-19 (Sars-Cov2) : (If Yes, Attach Prescription If No, Test Cannot Be Conducted)

    Uploaded by

    udayan
    211 views2 pages
    This document is an ICMR specimen referral form used to collect details of COVID-19 samples being tested. It requires information on the patient, doctor, specimen, symptoms, medical history and test results. Fields marked with an asterisk are mandatory. The form provides instructions to contact local health authorities for guidance on clinical specimen collection and transport.

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    0767000020270

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    This document is an ICMR specimen referral form used to collect details of COVID-19 samples being tested. It requires information on the patient, doctor, specimen, symptoms, medical history and test results. Fields marked with an asterisk are mandatory. The form provides instructions to contact local health authorities for guidance on clinical specimen collection and transport.

    Copyright:

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

    Icmr Specimen Referral Form For Covid-19 (Sars-Cov2) : (If Yes, Attach Prescription If No, Test Cannot Be Conducted)

    Uploaded by

    udayan
    This document is an ICMR specimen referral form used to collect details of COVID-19 samples being tested. It requires information on the patient, doctor, specimen, symptoms, medical history and test results. Fields marked with an asterisk are mandatory. The form provides instructions to contact local health authorities for guidance on clinical specimen collection and transport.

    Copyright:

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

    SRF ID: 0 7 6 7 0 0 0 0 2 0 2 7 0

    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
    Field marked with asterisk(*) are mandatory
    SECTION A – PATIENT DETAILS

    A.1 TEST INITIATION DETAILS


    *Doctor's Prescription : Yes No *Follow up Sample : Yes No
    (If yes, attach prescription; if no, test cannot be conducted) If yes, Patient ID :
    A.2 PERSON DETAILS
    *Patient Name: UDAYAN PANDEY *Age: 27 Years
    *Patient in quarantine facility: Yes No *Gender:Male Female Others
    *Present Village or Town: DELHI *Mobile Number: 8 2 9 9 6 7 4 5 7 5
    *District of present residence: NEW DELHI *Mobile number belongs to: Self Family
    *State of present residence: DELHI *Nationality: India
    *Patient's Present Address: NEW DELHI *Downloaded Aarogya Setu App: Yes No
    1100 (These fields to be filled for all patients including foreigners)
    Pin Code:
    Aadhaar No. (For Indians):
    Passport No. (for Foreign Nationals):
    *A.3 SPECIMEN INFORMATION FROM REFERRING AGENCY
    *Specimen type Throat Swab Nasal Swab BAL ETA Nasopharyngeal Swab
    *Collection date 29/06/2020 29/06/2020
    *Sample ID(Label) 1 1
    *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 Health care worker/Frontline workers
    Cat 4: Hospitalised SARI (Severe Acute Respiratory Illness) patient
    Cat 5a: Asymptomatic direct and high risk contact of lab confirmed case - family member
    Cat 5b: Asymptomatic health care worker in contact with confirmed case without adequate protection
    Cat 6: Symptomatic Influenza like Illness(ILI) in Hospital
    Cat 7: Pregnant women in/near labor
    Cat 8: Symptomatic (ILI) among returnees and migrants (within 7 days of illness)
    Cat 9: Symptomatic Influenza like Illness (ILI) patient in Hotspot/Containment zones
    Other :

    NIC-(https://covid19cc.nic.in) Page 1 of 2 6/29/2020 3:43:22 PM


    Section B- MEDICAL INFORMATION

    B.1 CLINICAL SYMPTOMS AND SIGNS


    Symptoms : Yes No If No please go to B.2 section

    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
    Which of the above mentioned was First Symptom: Cough Date of onset of First Symptoms: 20/06/2020 (dd/mm/yy)
    B.2 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.3 HOSPITALIZATION DETAILS
    Hospitalized : Yes No Hospital State:
    Hospital ID / Number: Hospital District:
    Hospitalization Date: (dd/mm/yy) Hospital Name:
    B.4 REFERRING DOCTOR DETAILS
    Doctor's Email ID:
    *Name of the Doctor: SELF Doctor's Mobile No.:

    Lab where sample is sent: CADMIPD - CARINGdx, Mahajan Imaging Pvt. Ltd., New Delhi

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


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

    NIC-(https://covid19cc.nic.in) Page 2 of 2 6/29/2020 3:43:22 PM

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