COVID-19 Specimen Submission Form
Kansas COVID-19 Testing Submission Form (07/24/2020)
PROVIDER INFORMATION
PATIENT INFORMATION
SPECIMEN INFORMATION
SYMPTOMS AND EXPOSURE INFORMATION
Facility Name: KHEL Facility ID: Clinician Name:
Facility Address: City: State: ZIP:
Existing KHEL facilities can contact KHEL Customer Service to change/verify report method (785) 296-1620 | kdhe.khel_help@ks.gov
NEW KHEL FACILITY ONLY — COMPLETE REPORT DELIVERY OPTIONS BELOW
Lab report delivery preference: Fax #: Secure Email:
• Ensure all information is completed for all patients.
• This form must be submitted with the specimen to KHEL
• This form is only for use when requesting SARS-CoV-2 testing at KHEL.
Last Name: First Name: Middle:
DOB: Mobile Phone: Home Phone:
Address: City: State: ZIP:
County of residence: Parent/Guardian Name:
Sex: Male Female Ethnicity: Non-Hispanic Hispanic Unknown
Race: White Black Asian American Indian/Alaska Native Native Hawaiian/Pacific Islander
Collection Date: Time: AM/PM Date test ordered:
Specimen type: Nasopharyngeal swab
Oropharyngeal (throat) swab
Blood/Serum (KDHE Epidemiology approval needed)
T
es
t
ordered: RT-PCR Antigen Serology Collected by: healthcare staff Self-collected
Symptom onset date of first symptom: Asymptomatic (no symptoms)
Fever (subjective/or measured:______ °F/°C) Cough Shortness of Breath Difficulty breathing
Sore Throat Loss of smell/taste Rigors or chills Myalgia or muscle aches Headache
Malaise or feeling very tired Pneumonia Diarrhea Nausea/vomiting Congestion/runny nose
Acute Respiratory Distress Syndrome
Immunocompromised/Chronic Condition? Yes, specify: No
Exposure?
NO PO BOX – PHYSICAL ADDRESS ONLY
Mid-turbinate (nasal swab)
Anterior nares (nasal swab)
For full instructions, visit:
https://www.coronavirus.kdheks.gov/170/Healthcare-Providers, Labs tab
