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    COVID 19 Lab Request Final,,,, 2.ori

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    daniel

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    © All Rights Reserved
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    COVID 19 Lab Request Final,,,, 2.ori

    Uploaded by

    daniel
    5 views2 pages

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    © All Rights Reserved
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    Download as docx, pdf, or txt
    5 views2 pages

    COVID 19 Lab Request Final,,,, 2.ori

    Uploaded by

    daniel

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    !

    !HEALTHIER CITIZENS FOR PROSPEROUS NATIONI

    COVID-19
    Test Request
    and
    Report Form
    COVID-19
    Test Request and Report Form
    !
    !HEALTHIER CITIZENS FOR PROSPEROUS NATIONI

    Client/Patient Information
    Full Name: Sex: AgeNationality
    Client current residency: Region: Sub-city/Zone Woreda
    Kebele/speci c area GPS (for in housecollection)
    House#

    Self-Phone: _______________ Relative Phone: ________________ Passport No: ____________________


    Occupation:Health care workerDriverGovernment employeeSelf employee
    Others
    Occupational Address: Region:Sub-city/Zone
    Woreda/areaName of institution
    Location of specimen collectionHealth Facility, specify___________
    Quarantine/isolation center, specifyCommunity
    Treatment centerOther, specify

    Specimen ID/Barcode No

    Clinical/other Information
    Does the patient/client have any symptom compatible with COVID-19? Yes No
    If yes, tick all that apply?CoughFeverShortness of breath Sore throat
    Headache Easy fatigue
    If yes, date of symptom onset: DD/MM/YYYY
    Does the patient have any chronic disease/condition?YesNo,
    If yes, specifyDiabetes MellitusHypertensionHIV
    respiratory diseaseChronic cardiac diseasePregnantOther Chronic
    Has the patient/client had contact with a con rmed case?YesNo
    If yesHouse-holdwork-placeOther, specify

    Has the patient/client had a recent Yes Country/ies:


    history of travel to area/s where No
    there is community transmission? City/towns/province
    Return date (DD/MM/YY)
    Reason for Testing Suspect New
    (tick all that apply) Contact of con rmed case Repeat
    Discharge from quarantine purpose Follow up I Follow up II
    Community surveillance Follow up III
    Discharge from treatment center Travel purpose

    Specimen Information
    Sample Type: NP, OP, Sputum, Blood, Urine OthersCollection Date: __/_____/2020
    Specimen Collection Time:Receiving date at the testing lab _____/_____/2020
    Sample Collected by:Phone:Sign: ____________
    Form completed by: ____________________ Phone: __________________Sign: _____________

    For Laboratory Use Only:


    Test requested:
    Test Method:RT-PCROthers_____________________________
    Laboratory Result:___________________________________
    Test done by: _____________________________ Sign: _______________ Date: _________Time:____________

    Result Reviewed and Approved by: __________ Signature: ______ Date: ___________Time:_______
    Note: A “Negative” result does not exclude infection with the reported
    pathogen.
    Falcon printing +251 11 470 9483/11 470 8373

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