Fillable COVID-19 and INFLUENZA A+B TESTING REQUISITION FORM ALL (Disease Prevention & Control - San Francisco Department of Public Health)

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COVID-19 and INFLUENZA A+B TESTING REQUISITION FORM ALL (Disease Prevention & Control - San Francisco Department of Public Health)

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Version: DPH Lab COVID Requisition Form 2021.02.10 Page1
CITY AND COUNTY OF SAN FRANCISCO
PUBLIC HEALTH LABORATORY
101 Grove Street, Room 419
San Francisco, CA 94102 THIS SPACE IS FOR LABORATORY USE ONLY
Tel: (415) 554-2800 Fax: (415) 431-0651
CLIA ID # 05D0643643
Director: Godfred Masinde, PhD
COVID-19 and INFLUENZA A+B TESTING REQUISITION FORM
Instructions:
• ALL FIELDS ON THE FORM ARE FEDERALLY MANDATED. EVERY FIELD MUST BE
COMPLETED OR SPECIMEN WILL BE REJECTED.
• Please type or print legibly.
• This form is intended for COVID-19 test requisitions only.
• Please include a printed copy of this form with the specimen submission.
• For electronic copies of this form, please visit our webpage at: https://www.sfcdcp.org/public-health-lab/forms-
specimen-culture-submission/.
Additional Information:
• For guidance on specimen collection and storage, please refer to SFDPH’s Clinical and Testing Guidance:
https://www.sfcdcp.org/infectious-diseases-a-to-z/coronavirus-2019-novel-coronavirus/coronavirus-2019-
information-for-healthcare-providers/
• Hospitals and large health systems are asked to provide transport of specimens to PHL between the hours of 8
AM and 8 PM Monday-Friday and 9 AM to 5 PM Saturday-Sunday. If you do not have the capacity to transport
specimen, SFDPH can arrange for scheduled transport. Please contact the Communicable Disease Control Unit
(CDCU) between the hours of 8 AM and 5 PM at (415) 554-2830 and follow the automated instructions to
schedule transport.
• Testing guidelines are subject to change. Please refer to the latest advisories here: https://www.sfcdcp.org/health-
alerts-emergencies/health-alerts/.
PLEASE COMPLETE REQUISITION FORM ON REVERSE SIDE. PLEASE ATTACH A COPY
WITH THE SPECIMEN.
Version: DPH Lab COVID Requisition Form 2021.02.10 Page2
CITY AND COUNTY OF SAN FRANCISCO
PUBLIC HEALTH LABORATORY
101 Grove Street, Room 419
San Francisco, CA 94102 THIS SPACE IS FOR LABORATORY USE ONLY
Tel: (415) 554-2800 Fax: (415) 431-0651
CLIA ID # 05D0643643
Director: Godfred Masinde, PhD
COVID-19 and INFLUENZA A+B TESTING REQUISITION FORM
ALL FIELDS ARE FEDERALLY MANDATED – Incomplete forms WILL be rejected. Please print legibly.
TEST REQUESTED (PLEASE USE ONE FORM PER SPECIMEN): □ COVID-19 Qualitative RT-PCR Testing ONLY
□ COVID-19 Qualitative RT-PCR Testing AND Influenza A+B RT-PCR Testing
Is the patient experiencing any of the following symptoms? □ Yes □ No □ Unknown Date of symptom onset? ____/_____/_____
• Fever or chills
• Cough
• Sore Throat
• Shortness of Breath
• Headache
• Diarrhea
• Muscle or body aches
• Fatigue
• Congestion or runny nose
• Loss of Small and Taste
• Nausea or vomiting
Is patient a resident of a congregate care setting? □ Yes □ No □ Unknown
Is the patient employed in healthcare? □ Yes □ No □ Unknown
Is the patient pregnant? □ Yes □ No □ Unknown
Has the patient been hospitalized? □ Yes □ No □ Unknown
Is the patient in the ICU? □ Yes □ No □ Unknown
IF PATIENT IS DECEASED
Date of Death: / / Name of Next of Kin:
Relation of Next of Kin: Phone: Email:
PATIENT INFORMATION
Patient’s Name:____________________________________, _____________________________________
Last First
Date of Birth: __ / / _ Medical Record #: __________________ Race: _____________ Ethnicity: _____________
(MM) (DD) (YYYY)
Sexual Orientation: _________________________ Gender: __________________ Gender Identity: ___________________
Patient’s Address: _______________________________________________________ City / State: __________________________
Zip Code: ___________________ County: ___________________________ Patient’s Phone: _______________________________
CLINIC INFORMATION
Submitting Clinic: Name/Address:
Phone# ____ Fax #: _____
Requesting Clinician: NPI: ____ Provider ID/CHN: __
Full Name (Last, First) (For SF Health Network Only)
SPECIMEN INFORMATION
COLLECTION DATE: COLLECTION TIME:
Specimen source (check one):
□ Nasopharyngeal (PREFERRED) □ Oropharyngeal □ NP/OP □ Tracheal Aspirate □ Sputum □ Anterior Nares
□ Pleural Fluid □ Nasal Mid-turbinate □ Nasopharyngeal Wash □ Bronchoalveolar Lavage (BAL) □Nasal Aspirate
□ Other: ____________________________
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Completed 31 March 2021

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