SAMPLE ID: 91761546 ICMR Specimen Referral Formfor COVID-19 (SARS-CoV2) INTRODUCTION This form is for collection centres/ labs to enter details of the samples being tested for Co mandatory to fill this form for each and every sample being tested. It is essential that the collection centres, Jabs exercise caution to ensure that correct information is captured in the form, © Inform the local / district / state health authorities, especially surveillance officer for further guidance © Seck guidance on requirements for the clinical specimen collection and transport from nodal officer This form may he 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: ‘Aa TEST INITIATION DETAILS “Doctor Prescription: Yes F No “Follow up Sample: ves Povo latyes, attach prescription: IFNo, test cannot be conducted) If Yes, Patient 1 .2 PERSONAL DETAILS, Patient Name: NAKKANA RAM NARAYAN PREM KUMAR, Patient in quarantine facility: Ves No —*Age:30Years/Month [7 (ifaxe-1 yr, pls. tiek months cheekbox) Present Village or Town: SIMHA 1 District of Present Residence:VISAKHAPATNAM “Gender: *State of Present Residence: “Mobile Numbe Present patient address: “Mobile Number belongs to: sell. family Simhachalam BR Female Others > 99515s8843, ationality ' Setu App: yesr>— NOW Pincode: 530028 “Downloaded Aarog (These fields to be filled for all pationts including foreigners) Aadhar No. (For Indians): 298076315028, Passport No. (For Foreign Nationals}: °A.3 SPECIMEN INFORMATION FROM REFERRING AGENCY Specimen type Throat Swab __Nasal Swab BAL ETAT _Nasopharyngeal swab 7 *Collection date 28-05-2021 01:27:50 PM ‘*Sample ID (Label) 91761546 *A.4 PATIENT CATEGORY (PLEASE SELECT ONLY ONE) Cal 1: Symptomatic international traveller in last 14 days, Cat 2: Symptomatic contact of lab confirmed case Cat 5: Symptomatic Healthcare worker / Frontline workers Gat 4: Hospitalized SARI (Severe Acute Respiratory Hlness) patient Gat 5a: Asymptomatic direct and high risk contact of lab confirmed case - family member Cat sh: Asymptomatic healthcare worker in contact with confirmed case without adequate protection. Gat 6: Symptomatic Influenza like Hlness (ILI) in Hospital Gat 7: Pregnant woman in / near labour Cat 8: Symptomatic (IL1) amongh returnees and mij illness) Gat o: Symptomatic Influenza Like Hlness(IL1) patient in Hotspot Containment zones Other: (please specily) * (Select “other” only if the patient doesn’t belong to category 1-8) ts (within 7 days ofSECTION B- MEDICAL INFORMATION B.1 CLINICAL SYMPTOMS AND SIGNS ‘symptoms: Yes Now If'No please go to B.2 section Symptoms Yes Symptoms Yes Symptoms Yes Symptoms Yes Symptoms Yes Cough jiarrhoea” Vomiting ~ Fever at evaluation[” Abdominal pain[~ Breathlessness” Nausea ~ Haemoptysis ~ Body acher™ Sore throat Chest pain” Nasal discharge” Sputum (~ Which of the above mentioned was First Symptor Date of onset of First Symptom (ddimmlyy) 2008-05- - a - ceseseceesneeeenseeeseeee24 00:00:00 B.2 PRE-EXISTING MEDICAL CONDITIONS. Condition Yes Condition Yes Condition Yes Condition Yes Chronic lung diseas[” Malignancy [~ Heart disease” Chronic liver disease[~ Chronic renal disease” Diabetes ~ Hypertension Immunocompromised condition: yes [~ No fy Other underlying conditions: B.3 HOSPITALIZATION DETAILS Hospitalize: Hospital 1D | number Hospitalization Date: (ddimmiyy) Yes Nor Hospital State: Andhra Pradesh Hospital District: oo Hospital Name: B.4 REFERRING DOCTOR DETAILS “Name of Doctor: Doctor Mobile No: Doctor Email 1D: * Fields marked with asterisk are mandatory to be filled TEST RESULT (To be led by Covid-19 tes! ig lab facility) Sample Date of Test result Repeat Sample Sign of Date of sample accepted) —Testing (Positive | required (Yes / Authority (Lab receipt(ddimmlyy) Rejected (ddimmtyy) Negative) No) in charge) 28-05-2021 ACCEPTED 28-05-2021 NEGATIVE 01:27:50 PM (03:50:14 PM