SRF ID (RTPCR): 2 4 4 6 2 0 0 0 8 1 4 7 7

Dais Photo

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

*Sample collected first time : Yes No
If No, Patient ID :
A.2 PERSONAL DETAILS
*Patient Name: ANIL GAMU BHOYA Father's Name:
*Age: 31 Years
*Gender:Male Female Others
*Occupation:Other
*Mobile Number: 9 5 1 0 8 3 6 6 1 4 *Mobile Number belongs to: Self Family
*Nationality: India
*Present patient address: MAKADBAN PATHSHALIFALIYA *Downloaded Aarogya Setu App: Yes No
Pincode:
*District : VALSAD *State : GUJARAT
(These fields to be filled for all patients including foreigners)
Aadhaar No. (For Indians):
* Passport No. (for Foreign Nationals):
Received COVID-19 vaccine Yes No
If yes type of vaccine
Date of Dose 1 : Date of Dose 2 :
*A.3 SPECIMEN INFORMATION FROM REFERRING AGENCY
Bronchoalveolar Endotracheal
*Specimen type Throat Swab Nasal Swab Nasopharyngeal Swab
lavage Aspirate
*Type of test RT-PCR Rapid Antigen Test (RAT)
*Collection date 27/04/2021
*Sample ID(Label) phc dhamni 887
If, RT-PCR test, name of lab where sample is sent for testing GMERSV - GMERS Medical College, Valsad
* Mode of Transport used to visit testing facility Public - Auto
Symptomatic Asymptomatic
Contact of a lab confirmed case : Yes No
Please Note - Hospital form is required for the patients visiting OPD, IPD and Emergency and Community form is required for patients
under containment zone/ Non-containment area/ Point of entry/ Testing on demand
*A.3.1 For Community

Not Applicable

NIC-(https://covid19cc.nic.in) Page 1/18 27-04-2021 13:49:04

 *A.3.2 For Hospital
Cat 12: Testing on Demand

* Fields marked with asterisk are mandatory to be filled

Please Note: Section B1 and B2 need to be filled for both Community and Hospital settings.
Section B3 needs to be filled only for Hospital settings
Section B- MEDICAL INFORMATION

B.1 CLINICAL SYMPTOMS AND SIGNS

Cough Loss of taste
Sore throat Diarrhoea
Fever Breathlessness
Loss of smell Other symptoms, please specify
Date of onset of First Symptom : 26/04/2021
B.2 PRE-EXISTING MEDICAL CONDITIONS
Diabetes Over weight/ Obesity
Heart disease Hypertension
Chronic lung disease Cancer
Chronic Kidney disease Any other please specify
B.3 HOSPITALIZATION DETAILS
Hospitalized : Yes No Hospital State:
Hospital District:
Hospitalization Date: Hospital Name:

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

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

NIC-(https://covid19cc.nic.in) Page 2/18 27-04-2021 13:49:04

 SRF ID (RTPCR): 2 4 4 6 2 0 0 0 8 1 4 8 8
Dais Photo

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

*Sample collected first time : Yes No
If No, Patient ID :
A.2 PERSONAL DETAILS
*Patient Name: GANU LAHNU BHOYA Father's Name:
*Age: 55 Years
*Gender:Male Female Others
*Occupation:Other
*Mobile Number: 9 9 7 9 6 0 8 6 5 2 *Mobile Number belongs to: Self Family
*Nationality: India
*Present patient address: MAKADBAN PATHSHALIFALIYA *Downloaded Aarogya Setu App: Yes No
Pincode:
*District : VALSAD *State : GUJARAT
(These fields to be filled for all patients including foreigners)
Aadhaar No. (For Indians):
* Passport No. (for Foreign Nationals):
Received COVID-19 vaccine Yes No
If yes type of vaccine
Date of Dose 1 : Date of Dose 2 :
*A.3 SPECIMEN INFORMATION FROM REFERRING AGENCY
Bronchoalveolar Endotracheal
*Specimen type Throat Swab Nasal Swab Nasopharyngeal Swab
lavage Aspirate
*Type of test RT-PCR Rapid Antigen Test (RAT)
*Collection date 27/04/2021
*Sample ID(Label) phc dhamni 888
If, RT-PCR test, name of lab where sample is sent for testing GMERSV - GMERS Medical College, Valsad
* Mode of Transport used to visit testing facility Public - Auto
Symptomatic Asymptomatic
Contact of a lab confirmed case : Yes No
Please Note - Hospital form is required for the patients visiting OPD, IPD and Emergency and Community form is required for patients
under containment zone/ Non-containment area/ Point of entry/ Testing on demand
*A.3.1 For Community

Not Applicable

NIC-(https://covid19cc.nic.in) Page 3/18 27-04-2021 13:49:04

 *A.3.2 For Hospital
Cat 12: Testing on Demand

* Fields marked with asterisk are mandatory to be filled

Please Note: Section B1 and B2 need to be filled for both Community and Hospital settings.
Section B3 needs to be filled only for Hospital settings
Section B- MEDICAL INFORMATION

B.1 CLINICAL SYMPTOMS AND SIGNS

Cough Loss of taste
Sore throat Diarrhoea
Fever Breathlessness
Loss of smell Other symptoms, please specify
Date of onset of First Symptom :
B.2 PRE-EXISTING MEDICAL CONDITIONS
Diabetes Over weight/ Obesity
Heart disease Hypertension
Chronic lung disease Cancer
Chronic Kidney disease Any other please specify
B.3 HOSPITALIZATION DETAILS
Hospitalized : Yes No Hospital State:
Hospital District:
Hospitalization Date: Hospital Name:

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
(dd/mm/yy) accepted/Rejected (dd/mm/yy) (Positive/Negative) required (Yes/No) Authority(Lab in
charge)

NIC-(https://covid19cc.nic.in) Page 4/18 27-04-2021 13:49:04

 SRF ID (RTPCR): 2 4 4 6 2 0 0 0 8 1 5 0 3
Dais Photo

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

*Sample collected first time : Yes No
If No, Patient ID :
A.2 PERSONAL DETAILS
*Patient Name: PINAL SOMA DHADHV Father's Name:
*Age: 20 Years
*Gender:Male Female Others
*Occupation:Other
*Mobile Number: 9 5 3 7 7 4 3 5 8 7 *Mobile Number belongs to: Self Family
*Nationality: India
*Present patient address: PHENDHA TAPALPADA *Downloaded Aarogya Setu App: Yes No
Pincode:
*District : VALSAD *State : GUJARAT
(These fields to be filled for all patients including foreigners)
Aadhaar No. (For Indians):
* Passport No. (for Foreign Nationals):
Received COVID-19 vaccine Yes No
If yes type of vaccine
Date of Dose 1 : Date of Dose 2 :
*A.3 SPECIMEN INFORMATION FROM REFERRING AGENCY
Bronchoalveolar Endotracheal
*Specimen type Throat Swab Nasal Swab Nasopharyngeal Swab
lavage Aspirate
*Type of test RT-PCR Rapid Antigen Test (RAT)
*Collection date 27/04/2021
*Sample ID(Label) phc dhamni 889
If, RT-PCR test, name of lab where sample is sent for testing GMERSV - GMERS Medical College, Valsad
* Mode of Transport used to visit testing facility Public - Auto
Symptomatic Asymptomatic
Contact of a lab confirmed case : Yes No
Please Note - Hospital form is required for the patients visiting OPD, IPD and Emergency and Community form is required for patients
under containment zone/ Non-containment area/ Point of entry/ Testing on demand
*A.3.1 For Community

Not Applicable

NIC-(https://covid19cc.nic.in) Page 5/18 27-04-2021 13:49:04

 *A.3.2 For Hospital
Cat 12: Testing on Demand

* Fields marked with asterisk are mandatory to be filled

Please Note: Section B1 and B2 need to be filled for both Community and Hospital settings.
Section B3 needs to be filled only for Hospital settings
Section B- MEDICAL INFORMATION
B.1 CLINICAL SYMPTOMS AND SIGNS
Cough Loss of taste
Sore throat Diarrhoea
Fever Breathlessness
Loss of smell Other symptoms, please specify
Date of onset of First Symptom : 26/04/2021
B.2 PRE-EXISTING MEDICAL CONDITIONS
Diabetes Over weight/ Obesity
Heart disease Hypertension
Chronic lung disease Cancer
Chronic Kidney disease Any other please specify
B.3 HOSPITALIZATION DETAILS
Hospitalized : Yes No Hospital State:
Hospital District:
Hospitalization Date: Hospital Name:

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

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

NIC-(https://covid19cc.nic.in) Page 6/18 27-04-2021 13:49:04

 SRF ID (RTPCR): 2 4 4 6 2 0 0 0 8 1 5 1 5
Dais Photo

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

*Sample collected first time : Yes No
If No, Patient ID :
A.2 PERSONAL DETAILS
*Patient Name: HITESH MAHDU JANJAR Father's Name:
*Age: 30 Years
*Gender:Male Female Others
*Occupation:Other
*Mobile Number: 9 9 7 9 6 7 5 8 4 6 *Mobile Number belongs to: Self Family
*Nationality: India
*Present patient address: DHAMNI MUDGAM *Downloaded Aarogya Setu App: Yes No
Pincode:
*District : VALSAD *State : GUJARAT
(These fields to be filled for all patients including foreigners)
Aadhaar No. (For Indians):
* Passport No. (for Foreign Nationals):
Received COVID-19 vaccine Yes No
If yes type of vaccine
Date of Dose 1 : Date of Dose 2 :
*A.3 SPECIMEN INFORMATION FROM REFERRING AGENCY
Bronchoalveolar Endotracheal
*Specimen type Throat Swab Nasal Swab Nasopharyngeal Swab
lavage Aspirate
*Type of test RT-PCR Rapid Antigen Test (RAT)
*Collection date 27/04/2021
*Sample ID(Label) phc dhamni 890
If, RT-PCR test, name of lab where sample is sent for testing GMERSV - GMERS Medical College, Valsad
* Mode of Transport used to visit testing facility Public - Auto
Symptomatic Asymptomatic
Contact of a lab confirmed case : Yes No
Please Note - Hospital form is required for the patients visiting OPD, IPD and Emergency and Community form is required for patients
under containment zone/ Non-containment area/ Point of entry/ Testing on demand
*A.3.1 For Community

Not Applicable

NIC-(https://covid19cc.nic.in) Page 7/18 27-04-2021 13:49:04

 *A.3.2 For Hospital
Cat 12: Testing on Demand

* Fields marked with asterisk are mandatory to be filled

Please Note: Section B1 and B2 need to be filled for both Community and Hospital settings.
Section B3 needs to be filled only for Hospital settings
Section B- MEDICAL INFORMATION
B.1 CLINICAL SYMPTOMS AND SIGNS
Cough Loss of taste
Sore throat Diarrhoea
Fever Breathlessness
Loss of smell Other symptoms, please specify
Date of onset of First Symptom : 26/04/2021
B.2 PRE-EXISTING MEDICAL CONDITIONS
Diabetes Over weight/ Obesity
Heart disease Hypertension
Chronic lung disease Cancer
Chronic Kidney disease Any other please specify
B.3 HOSPITALIZATION DETAILS
Hospitalized : Yes No Hospital State:
Hospital District:
Hospitalization Date: Hospital Name:

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 8/18 27-04-2021 13:49:04

 SRF ID (RTPCR): 2 4 4 6 2 0 0 0 8 1 5 2 5
Dais Photo

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

*Sample collected first time : Yes No
If No, Patient ID :
A.2 PERSONAL DETAILS
*Patient Name: VISHAL VIJAY PATEL Father's Name:
*Age: 25 Years
*Gender:Male Female Others
*Occupation:Other
*Mobile Number: 8 2 0 0 3 2 1 2 5 2 *Mobile Number belongs to: Self Family
*Nationality: India
*Present patient address: SERIMAD NADIFALIYA *Downloaded Aarogya Setu App: Yes No
Pincode:
*District : VALSAD *State : GUJARAT
(These fields to be filled for all patients including foreigners)
Aadhaar No. (For Indians):
* Passport No. (for Foreign Nationals):
Received COVID-19 vaccine Yes No
If yes type of vaccine
Date of Dose 1 : Date of Dose 2 :
*A.3 SPECIMEN INFORMATION FROM REFERRING AGENCY

Throat Swab Nasal Swab Bronchoalveolar Endotracheal Nasopharyngeal Swab

*Specimen type lavage Aspirate
*Type of test RT-PCR Rapid Antigen Test (RAT)
*Collection date 27/04/2021
*Sample ID(Label) phc dhamni 891
If, RT-PCR test, name of lab where sample is sent for testing GMERSV - GMERS Medical College, Valsad
* Mode of Transport used to visit testing facility Public - Auto
Symptomatic Asymptomatic
Contact of a lab confirmed case : Yes No
Please Note - Hospital form is required for the patients visiting OPD, IPD and Emergency and Community form is required for patients
under containment zone/ Non-containment area/ Point of entry/ Testing on demand
*A.3.1 For Community

Not Applicable

NIC-(https://covid19cc.nic.in) Page 9/18 27-04-2021 13:49:04

 *A.3.2 For Hospital
Cat 12: Testing on Demand

* Fields marked with asterisk are mandatory to be filled

Please Note: Section B1 and B2 need to be filled for both Community and Hospital settings.
Section B3 needs to be filled only for Hospital settings
Section B- MEDICAL INFORMATION

B.1 CLINICAL SYMPTOMS AND SIGNS

Cough Loss of taste
Sore throat Diarrhoea
Fever Breathlessness
Loss of smell Other symptoms, please specify
Date of onset of First Symptom :
B.2 PRE-EXISTING MEDICAL CONDITIONS
Diabetes Over weight/ Obesity
Heart disease Hypertension
Chronic lung disease Cancer
Chronic Kidney disease Any other please specify
B.3 HOSPITALIZATION DETAILS
Hospitalized : Yes No Hospital State:
Hospital District:
Hospitalization Date: Hospital Name:

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
(dd/mm/yy) accepted/Rejected (dd/mm/yy) (Positive/Negative) required (Yes/No) Authority(Lab in
charge)

NIC-(https://covid19cc.nic.in) Page 10/18 27-04-2021 13:49:04

 SRF ID (RTPCR): 2 4 4 6 2 0 0 0 8 1 5 3 4
Dais Photo

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

*Sample collected first time : Yes No
If No, Patient ID :
A.2 PERSONAL DETAILS
*Patient Name: JIGISHA JAGDISH AHIR Father's Name:
*Age: 23 Years
*Gender:Male Female Others
*Occupation:Other
*Mobile Number: 8 8 6 6 6 5 5 5 7 1 *Mobile Number belongs to: Self Family
*Nationality: India
*Present patient address: DHARAMPUR 3 *Downloaded Aarogya Setu App: Yes No
DARVAJA Pincode:
*District : VALSAD *State : GUJARAT
(These fields to be filled for all patients including foreigners)
Aadhaar No. (For Indians):
* Passport No. (for Foreign Nationals):
Received COVID-19 vaccine Yes No
If yes type of vaccine
Date of Dose 1 : Date of Dose 2 :
*A.3 SPECIMEN INFORMATION FROM REFERRING AGENCY

Throat Swab Nasal Swab Bronchoalveolar Endotracheal Nasopharyngeal Swab

*Specimen type
lavage Aspirate
*Type of test RT-PCR Rapid Antigen Test (RAT)
*Collection date 27/04/2021
*Sample ID(Label) phc dhamni 892
If, RT-PCR test, name of lab where sample is sent for testing GMERSV - GMERS Medical College, Valsad
* Mode of Transport used to visit testing facility Public - Auto
Symptomatic Asymptomatic
Contact of a lab confirmed case : Yes No
Please Note - Hospital form is required for the patients visiting OPD, IPD and Emergency and Community form is required for patients
under containment zone/ Non-containment area/ Point of entry/ Testing on demand
*A.3.1 For Community

Not Applicable

NIC-(https://covid19cc.nic.in) Page 11/18 27-04-2021 13:49:04

 *A.3.2 For Hospital
Cat 12: Testing on Demand

* Fields marked with asterisk are mandatory to be filled

Please Note: Section B1 and B2 need to be filled for both Community and Hospital settings.
Section B3 needs to be filled only for Hospital settings
Section B- MEDICAL INFORMATION
B.1 CLINICAL SYMPTOMS AND SIGNS
Cough Loss of taste
Sore throat Diarrhoea
Fever Breathlessness
Loss of smell Other symptoms, please specify
Date of onset of First Symptom :
B.2 PRE-EXISTING MEDICAL CONDITIONS
Diabetes Over weight/ Obesity
Heart disease Hypertension
Chronic lung disease Cancer
Chronic Kidney disease Any other please specify
B.3 HOSPITALIZATION DETAILS
Hospitalized : Yes No Hospital State:
Hospital District:
Hospitalization Date: Hospital Name:

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 12/18 27-04-2021 13:49:04

 SRF ID (RTPCR): 2 4 4 6 2 0 0 0 8 1 5 4 3
Dais Photo

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

*Sample collected first time : Yes No
If No, Patient ID :
A.2 PERSONAL DETAILS
*Patient Name: JIGNESH GULAB KUVAR Father's Name:
*Age: 26 Years
*Gender:Male Female Others
*Occupation:Other
*Mobile Number: 9 6 8 7 2 6 1 5 5 0 *Mobile Number belongs to: Self Family
*Nationality: India
*Present patient address: FULWADI PARFALIYA *Downloaded Aarogya Setu App: Yes No
Pincode:
*District : VALSAD *State : GUJARAT
(These fields to be filled for all patients including foreigners)
Aadhaar No. (For Indians):
* Passport No. (for Foreign Nationals):
Received COVID-19 vaccine Yes No
If yes type of vaccine
Date of Dose 1 : Date of Dose 2 :
*A.3 SPECIMEN INFORMATION FROM REFERRING AGENCY
Bronchoalveolar Endotracheal
*Specimen type Throat Swab Nasal Swab Nasopharyngeal Swab
lavage Aspirate
*Type of test RT-PCR Rapid Antigen Test (RAT)
*Collection date 27/04/2021
*Sample ID(Label) phc dhamni 893
If, RT-PCR test, name of lab where sample is sent for testing GMERSV - GMERS Medical College, Valsad
* Mode of Transport used to visit testing facility Public - Auto
Symptomatic Asymptomatic
Contact of a lab confirmed case : Yes No
Please Note - Hospital form is required for the patients visiting OPD, IPD and Emergency and Community form is required for patients
under containment zone/ Non-containment area/ Point of entry/ Testing on demand
*A.3.1 For Community

Not Applicable

NIC-(https://covid19cc.nic.in) Page 13/18 27-04-2021 13:49:04

 *A.3.2 For Hospital
Cat 12: Testing on Demand

* Fields marked with asterisk are mandatory to be filled

Please Note: Section B1 and B2 need to be filled for both Community and Hospital settings.
Section B3 needs to be filled only for Hospital settings
Section B- MEDICAL INFORMATION

B.1 CLINICAL SYMPTOMS AND SIGNS

Cough Loss of taste
Sore throat Diarrhoea
Fever Breathlessness
Loss of smell Other symptoms, please specify
Date of onset of First Symptom :
B.2 PRE-EXISTING MEDICAL CONDITIONS
Diabetes Over weight/ Obesity
Heart disease Hypertension
Chronic lung disease Cancer
Chronic Kidney disease Any other please specify
B.3 HOSPITALIZATION DETAILS
Hospitalized : Yes No Hospital State:
Hospital District:
Hospitalization Date: Hospital Name:

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 14/18 27-04-2021 13:49:04

 SRF ID (RTPCR): 2 4 4 6 2 0 0 0 8 1 5 5 1
Dais Photo

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

*Sample collected first time : Yes No
If No, Patient ID :
A.2 PERSONAL DETAILS
*Patient Name: SANDIP JIVALU JADAV Father's Name:
*Age: 34 Years
*Gender:Male Female Others
*Occupation:Other
*Mobile Number: 6 3 5 5 9 6 3 4 6 7 *Mobile Number belongs to: Self Family
*Nationality: India
*Present patient address: TISKARI DONIFALIYA *Downloaded Aarogya Setu App: Yes No
Pincode:
*District : VALSAD *State : GUJARAT
(These fields to be filled for all patients including foreigners)
Aadhaar No. (For Indians):
* Passport No. (for Foreign Nationals):
Received COVID-19 vaccine Yes No
If yes type of vaccine
Date of Dose 1 : Date of Dose 2 :
*A.3 SPECIMEN INFORMATION FROM REFERRING AGENCY
Bronchoalveolar Endotracheal
*Specimen type Throat Swab Nasal Swab Nasopharyngeal Swab
lavage Aspirate
*Type of test RT-PCR Rapid Antigen Test (RAT)
*Collection date 27/04/2021
*Sample ID(Label) phc dhamni 894
If, RT-PCR test, name of lab where sample is sent for testing GMERSV - GMERS Medical College, Valsad
* Mode of Transport used to visit testing facility Public - Auto
Symptomatic Asymptomatic
Contact of a lab confirmed case : Yes No
Please Note - Hospital form is required for the patients visiting OPD, IPD and Emergency and Community form is required for patients
under containment zone/ Non-containment area/ Point of entry/ Testing on demand
*A.3.1 For Community

Not Applicable

NIC-(https://covid19cc.nic.in) Page 15/18 27-04-2021 13:49:04

 *A.3.2 For Hospital
Cat 12: Testing on Demand

* Fields marked with asterisk are mandatory to be filled

Please Note: Section B1 and B2 need to be filled for both Community and Hospital settings.
Section B3 needs to be filled only for Hospital settings
Section B- MEDICAL INFORMATION

B.1 CLINICAL SYMPTOMS AND SIGNS

Cough Loss of taste
Sore throat Diarrhoea
Fever Breathlessness
Loss of smell Other symptoms, please specify
Date of onset of First Symptom :
B.2 PRE-EXISTING MEDICAL CONDITIONS
Diabetes Over weight/ Obesity
Heart disease Hypertension
Chronic lung disease Cancer
Chronic Kidney disease Any other please specify
B.3 HOSPITALIZATION DETAILS
Hospitalized : Yes No Hospital State:
Hospital District:
Hospitalization Date: Hospital Name:

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 16/18 27-04-2021 13:49:04

 SRF ID (RTPCR): 2 4 4 6 2 0 0 0 8 1 5 6 0
Dais Photo

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

*Sample collected first time : Yes No
If No, Patient ID :
A.2 PERSONAL DETAILS
*Patient Name: MOSMI SHUBHAS BHISRA Father's Name:
*Age: 33 Years
*Gender:Male Female Others
*Occupation:Other
*Mobile Number: 9 9 0 4 0 6 2 5 4 2 *Mobile Number belongs to: Self Family
*Nationality: India
*Present patient address: NANAPHODHA BHISRA *Downloaded Aarogya Setu App: Yes No
FALIYA Pincode:
*District : VALSAD *State : GUJARAT
(These fields to be filled for all patients including foreigners)
Aadhaar No. (For Indians):
* Passport No. (for Foreign Nationals):
Received COVID-19 vaccine Yes No
If yes type of vaccine
Date of Dose 1 : Date of Dose 2 :
*A.3 SPECIMEN INFORMATION FROM REFERRING AGENCY
Bronchoalveolar Endotracheal
*Specimen type Throat Swab Nasal Swab Nasopharyngeal Swab
lavage Aspirate
*Type of test RT-PCR Rapid Antigen Test (RAT)
*Collection date 27/04/2021
*Sample ID(Label) phc dhamni 895
If, RT-PCR test, name of lab where sample is sent for testing GMERSV - GMERS Medical College, Valsad
* Mode of Transport used to visit testing facility Public - Auto
Symptomatic Asymptomatic
Contact of a lab confirmed case : Yes No
Please Note - Hospital form is required for the patients visiting OPD, IPD and Emergency and Community form is required for patients
under containment zone/ Non-containment area/ Point of entry/ Testing on demand
*A.3.1 For Community

Not Applicable

NIC-(https://covid19cc.nic.in) Page 17/18 27-04-2021 13:49:04

 *A.3.2 For Hospital
Cat 12: Testing on Demand

* Fields marked with asterisk are mandatory to be filled

Please Note: Section B1 and B2 need to be filled for both Community and Hospital settings.
Section B3 needs to be filled only for Hospital settings
Section B- MEDICAL INFORMATION

B.1 CLINICAL SYMPTOMS AND SIGNS

Cough Loss of taste
Sore throat Diarrhoea
Fever Breathlessness
Loss of smell Other symptoms, please specify
Date of onset of First Symptom :
B.2 PRE-EXISTING MEDICAL CONDITIONS
Diabetes Over weight/ Obesity
Heart disease Hypertension
Chronic lung disease Cancer
Chronic Kidney disease Any other please specify
B.3 HOSPITALIZATION DETAILS
Hospitalized : Yes No Hospital State:
Hospital District:
Hospitalization Date: Hospital Name:

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 18/18 27-04-2021 13:49:04