Fillable District of Columbia Department of Forensic Sciences Public (Government of the District of Columbia)

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District of Columbia Department of Forensic Sciences Public (Government of the District of Columbia)

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Last updated: 01/22/2021
District of Columbia
Department of Forensic Sciences
Public Health Laboratory
401 E Street SW 4
th
Floor Washington, DC 20024 Phone (202) 727-8956 Fax (202) 481-3464
COVID-19 Test Requisit ion Form
CLIA Director: Ju lia Kieh lb au ch, Ph . D., D(ABMM)
CLIA#: 09D0968273
Patient Information *Required Information
Last Name*
First Name*
Middle Initial
Suffix
Date of Birth*
(MM/DD/YYYY)
Sex*
Male Female Other
Race/Ethnicity
Address *
City*
State*
Sample ID (Laboratory ID, Outbreak#, Zika#, etc.)*
Medical Record Number
Submitter Information
Name of Submitting Hospital, Laboratory, or other Facility*
Healthcare Provider NPI #*
Health Care Provider
Last Name*
First Name*
Address (include room)*
City*
State*
Zip*
Primary Contact
(If not the Health Care Provider)
Last Name
First Name
Telephone #*
(primary)
Secure Fax #**
Email
Specimen Information
Date of Collection* (MM/DD/YYYY):
Time of Collection*:
AM
PM
Collection Method:
Provider Collection Self Collection (Provider O bse rved) Self Collection
Reason for Submission*
Diagnostic Outbreak DC Health Request: DC Health Contact:_________________
Specimen Type (check all that apply)*
Aptima Multitest Specimen Tube (Orange Label) Aptima Specimen Transfer Tube (Green Label) Swab UTM VTM
Sterile Container Blood Tube (Plasma, Serum or Whole Blood)_____________ Other (specify)____________________
Specimen Source*
Bronchoalveolar Lavage Bronchial Wash Nasal- Mid Turbinate Nasal- Anterior Nares Nasopharyngeal (NP)
Oropharyngeal (OP) NP/OP (Dual Swabs) Sputum, expectorated Sputum, induced Throat
Other (specify)_______________
Test Request ( requested tests)
SARS CoV-2 Molecular Test (RT-PCR) SARS CoV-2 Serology Test (IgG only)
Covid-19 Vaccine *
Yes
No
Moderna 1
st
Dose Only 1
st
and 2
nd
Dose Dates of Vaccination(s): ___________________
Pfizer
1
st
Dose Only
1
st
and 2
nd
Dose Dates of Vaccination(s): ___________________
Clinical Symptoms (Please check all that apply) *
Te st Pr iority
Has the patient experienced any symptoms?
Yes
No Earliest Symptom Onset Date? _____________
Fever
Fatigue/Tiredness
Sore Throat
Shortness of breath/difficulty breathing
Cough
Altered Mental Status/ Disoriented/
Confusion
Chills
Muscle Pain
Nausea/vomiting/diarrhea
New Loss of Taste or Smell
Headache
Other________________________
Routine Test Requested
STAT/Priority Test Requested
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District of Columbia Department of Forensic Sciences Public (Government of the District of Columbia)

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Completed 31 March 2021

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