SRFID (RTPCR): 2 9 5 4 8 0 1 3 8 1 2 5 2

ICMRSpecimenReferralFormforCOVID-19(SARS-CoV2)

INTRODUCTION:
Thisformisforcollectioncentres/labstoenterdetailsofthesamplesbeingtestedforCovid-19.Itismandatorytofillthisformforeach andevery
samplebeingtested.Itisessentialthatthecollectioncentres/labsexercisecautiontoensurethatcorrectinformationis capturedintheform.
INSTRUCTIONS:
Informthelocal/district/statehealthauthorities,especiallysurveillanceofficerforfurtherguidance
Seekguidanceonrequirementsfortheclinicalspecimencollectionandtransportfromnodalofficer
ThisformmaybefilledinandsharedwiththeIDSPandforwardedtoalabwheretestingisplanned Fields
markedwithasterisk(*)aremandatorytobefilled
SECTION A – PATIENT DETAILS
A.1 TEST INITIATION DETAILS
*Samplecollectedfirsttime: Yes No If
No,PatientID:
A.2 PERSONAL DETAILS
*PatientName:SHOBHITH K N Father'sName:
*Age: 27 Years
*Gender:Male Female Transgender
*Occupation:Other
*Mobile Number: 7 2 5 9 3 8 3 3 2 9 *Mobile Numberbelongsto:Patient Family
*Nationality: India
*Presentpatientaddress: ASHOK NAGARA *DownloadedAarogyaSetuApp: Yes No
8TH CROSS TUMKUR URBAN Pincode: - - - - - - Urban
*District:TUMAKURU *State :KARNATAKA
(These fields tobe filledfor all patients including foreigners)
AadhaarNo.(ForIndians):
*PassportNo.(forForeignNationals):
Received COVID-19vaccine Yes No
IfyestypeofvaccineCovishield
DateofDose1:14/07/2021 Dose2:No DateofDose2:
*A.3 SPECIMEN INFORMATION FROM REFERRING AGENCY
ThroatSwab NasalSwab Endotracheal
*Specimentype NasopharyngealSwab
lavage Aspirate
Bronchoalveolar

*Typeoftest RT-PCR Rapid Antigen Test (RAT)

*Collectiondate 11/08/2021
*SampleID(Label) 3
If,RT-PCRtest,nameoflabwheresampleissentfortestingKRAG282 - District Hospital, Tumakuru
*ModeofTransportusedtovisittestingfacility Symptomatic
Asymptomatic
Contactofalabconfirmedcase: Yes No
PleaseNote-HospitalformisrequiredforthepatientsvisitingOPD,IPDandEmergencyandCommunityformisrequiredforpatients under
containmentzone/Non-containmentarea/Pointofentry/Testingondemand
*A.3.1 For Community
Not Applicable

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 *A.3.2 For Hospital
Cat 6: All symptomatic (ILI symptoms) patients presenting in a health care setting

* 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 Lossoftaste
Sorethroat Diarrhoea
Fever Breathlessness
Lossofsmell Othersymptoms,pleasespecify
DateofonsetofFirstSymptom: 11/08/2021
B.2 PRE-EXISTING MEDICAL CONDITIONS
Diabetes Overweight/Obesity
Heartdisease Hypertension
Chroniclungdisease Cancer
ChronicKidneydisease Anyotherpleasespecify
B.3 HOSPITALIZATION DETAILS
Hospitalized: Yes No HospitalState:
Hospital District:
Hospitalization Date: HospitalName:

Rapid Antigen Test

NameofkitusedSD Biosensor Standard Q COVID-19 Ag Detection Kit
DateofTesting11/08/2021 12:25PM Testresult:Antigen Negative

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

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

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