Medical Provider of COVID-19 Laboratory Results – acd-COVID19MedProviderNotification (9/5/20) Page 1 of 1
CONFIDENTIAL – This material is subject to the Official Information Privilege Act
MEDICAL PROVIDER INFORMATION
Physician/Infection Preventionist Name
Facility Name
Physician/ Infection Preventionist Pager/Phone number E-mail Address Date of Report
PATIENT INFORMATION
Patient Name-Last, First, Middle Initial Facility name (if not living at home): Date of Birth Age
Patient’s current gender identity? (select one option/response)
Male Female Transgender Male/Trans Man Transgender Female/Trans Woman
Gender Non-Binary, Gender Non-Conforming Other: ______________________ Prefer not to state
Patient’s sex at birth? Male Female
Non-Binary or X Other: _________
Prefer not to answer
Sexual Orientation: Do you consider yourself to be…
Gay or Lesbian Bisexual Straight or Heterosexual Not sure Something else: ______________________________
Don’t understand the question Prefer not to state
Patient’s race or ethnicity? (check all that apply) White Hispanic/Latino/Spanish origin Black/African-American Asian
American Indian/Alaskan Native Native Hawaiian/Other Pacific Islander Other: __________________________ Refused
Address- Number, Street, Apt # City State ZIP Code
Primary Phone Number Alternative Phone Number Email Address
Patient currently resides in: Private residence Hotel Homeless Detention facility Nursing home/long-term healthcare
Residential Care/Assisted Living School/University dorm Military base Shelter Other: ________________________________
Occupation: Healthcare Worker: If Hospital: Unit & Floor? __________________ Teacher First Responder (fire, police, EMT) Other: ______________
CLINICAL INFORMATION
Symptomatic? Yes No
If Yes, Date of onset Hospitalized?
Yes No
Date of admission Medical Record Number
Severe Acute Lower Respiratory Illness: ( pneumonia OR ARDS): Chest x-ray/CT results: ____________________________________
Pre-existing medical conditions (check all that apply):
Pregnancy Diabetes Hypertension Cardiovascular disease Chronic pulmonary disease
Asthma Chronic renal disease Chronic liver disease Immunocompromised Neurologic disability
Other:_____________________________________________________
LABORATORY INFORMATION
Specimen type Test performed Collection date Result Performing lab name
NP swab OP swab
Sputum Serum
Other: ___________
PCR/NAAT
Rapid Antigen
Other: ______________
NP swab OP swab
Sputum Serum
Other: ___________
PCR/NAAT
Rapid Antigen
Other: ______________
NP swab OP swab
Sputum Serum
Other: ___________
PCR/NAAT
Rapid Antigen
Other: ______________
Influenza Virus Type A and/or B within 30 days before or after positive COVID test? Positive Negative Not tested
Date specimen collected: _____________ Test type:
PCR/NAAT Rapid Antigen Other:________________________
SEND COMPLETED FORM TO THE ACUTE COMMUNICABLE DISEASE CONTROL PROGRAM
BY FAX at (310) 605-4274 or SECURE EMAIL to COVID19@ph.lacounty.gov.
Medical Provider Report of
COVID-19 Laboratory Results
**FORM MUST BE TYPED OR THE AUTOMATED SYSTEM
WILL REJECT THE REPORT**
cute Communicable Disease Control
313 N. Figueroa St., Rm. 212
Los Angeles, CA 90012
213-240-7941 (phone), 213-482-4856 (facsimile)
publichealth.lacounty.gov/acd/
