Fillable KDHE COVID-19 Testing Approval Form - Self Submit

Fill Online, Printable, Fillable, Blank KDHE COVID-19 Testing Approval Form - Self Submit Form

Use Fill to complete blank online KANSAS DEPARTMENT OF HEALTH AND ENVIRONMENT (KS) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

KDHE Coronavirus Disease 2019 (COVID-19) Testing COVID-19 Testing Approval Form -Self Submit

On average this form takes 16 minutes to complete

The KDHE COVID-19 Testing Approval Form - Self Submit form is 2 pages long and contains:

  • 1 signature
  • 38 check-boxes
  • 42 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Kansas Department of Health and Environment

BROWSE KANSAS DEPARTMENT OF HEALTH AND ENVIRONMENT (KS) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
KDHE Coronavirus Disease 2019 (COVID-19) Testing
Kansas COVID-19 PUI Criteria, Testing Form, and Shipping Guidance (04/08/2020)
Facilities and providers should prioritize using internal or commercial laboratory testing for COVID-19. The
following reference labs offer COVID-19 testing: Quest Diagnostics (test code 39433), LabCorp (test code
139900), Mayo Clinic Laboratories (test code ZW282), and Viracor (test code 8398). Testing at the Kansas
Health and Environmental Laboratories will be prioritized for public health purposes and urgent need.
If you are unable to test at a reference laboratory, fill out the following criteria to ensure that your
patient meets the definition of a Person Under Investigation (PUI) and will be approved for testing. If
the criteria are not met, COVID-19 testing may not be conducted.
¥
Epidemiologic Risk
&
Clinical Features
Close contact^ with a person that
has laboratory-confirmed COVID-
19 and developed symptoms
within 14 days of contact
and
At least two of the following symptoms, without an
alternate more likely diagnosis:
Fever*
Chills
Rigors
Myalgia
Malaise
Headache
Sore throat
Lower respiratory illness (cough, shortness of
breath, or difficulty breathing)
New olfactory and taste disorders
History of travel
§
within 14 days of
symptom onset
and
Fever* and at least two of the following symptoms,
without an alternate more likely diagnosis:
Chills
Rigors
Myalgia
Malaise
Headache
Sore throat
Lower respiratory illness (cough, shortness of
breath, or difficulty breathing)
New olfactory and taste disorders
No source of exposure has been
identified
¥
Persons outside of this testing criteria may be considered for testing. These would include persons with unusual early
symptoms such as a sudden loss of taste or smell, or sudden onset of malaise with fever. Record these symptoms in
the Symptoms and Exposure Information section of the KDHE Coronavirus Disease 2019 (COVID-19) Testing form.
^ Being within 6 feet for a prolonged period (10 minutes or longer) or having direct contact with infectious secretions of a
COVID-19 case (e.g., being coughed on)
*
Measured fever of 100.4°F. Fever CANNOT be subjective
§
History of travel includes travel outside of the U.S. to countries with travel advisories
(https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html
), travel to states with cases of COVID-19
(https://www.cdc.gov/coronavirus/2019-ncov/cases-in-us.html), and attendance to mass gatherings (e.g. conferences,
cruises, concerts).
KDHE Coronavirus Disease 2019 (COVID-19) Testing
Kansas COVID-19 PUI Criteria, Testing Form, and Shipping Guidance (04/08/2020)
PROVIDER INFORMATION
PATIENT INFORMATION
SPECIMEN COLLECTION AND SHIPPING INSTRUCTIONS
SYMPTOMS AND EXPOSURE INFORMATION
Facility Name: KHEL Facility ID: Clinician Name:
Facility Address: City: State: ZIP:
24/7 Phone Number for Positive Results (e.g., Hospital Lab, Infection Prevention):
Lab report delivery preference: ☐ Fax #: ☐ Secure Email:
• Patients not meeting Person Under Investigation (PUI) criteria will be rejected.
• Fax the completed form to 877-427-7318. Calling the hotline is no longer required.
• Include a copy of the form with the specimen shipment to KHEL.
• Forms with missing information will be rejected.
Name (Last, First): DOB:
☐
Male
☐
Female
Address: City: State: ZIP:
Home Phone Number: Parent/Guardian Name:
Mobile Phone Number: Ethnicity: ☐ Non-Hispanic ☐ Hispanic ☐ Unknown
Race: ☐ White ☐ Black ☐ Asian ☐ Amer. Indian/Alaska Native ☐ Native Hawaiian/Pacific Islander
NASOPHARYNGEAL SWAB Collection Date: Time: AM/PM *Collection Date is Required*
An oropharyngeal swab is not required. Ensure specimen is closed tightly to avoid leaking while shipping.
Clinician Signature: Date:
**By signing this form, you are agreeing that this person meets Kansas PUI criteria for testing. This form can be digitally signed.
Symptoms: ☐ Fever:______ °F/°C ☐ Cough ☐ Shortness of Breath ☐ Pneumonia ☐ Acute Respiratory Distress
Immunocompromised? ☐ Yes, specify: ☐ No
Chronic medical condition? ☐ Yes, specify: ☐ No
Hospitalized? ☐ Yes ☐ No Healthcare Worker? ☐ Yes ☐ No First Responder? ☐ Yes ☐ No
Long-term care or Group Setting? ☐ Yes ☐ No
Other Symptoms, Risk/Exposure info:
NOTE: Non-hospitalized patients should remain in home isolation until laboratory results are available.
**See below for specimen collection and shipping instructions**
**Samples collected or shipped not in accordance with below instructions will be unsatisfactory for testing**
KDHE lab use only
click to sign
signature
click to edit
KDHE Coronavirus Disease 2019 (COVID-19) Testing
Kansas COVID-19 PUI Criteria, Testing Form, and Shipping Guidance (04/08/2020)
Specimen Collection and Shipping Instructions
• Fill out the above KDHE Coronavirus Disease 2019 (COVID-19) Testing Form above. Include a copy of
the form with the specimen shipment. In addition, fax the form to 877-427-7318.
• Collect a nasopharyngeal (NP) swab using a synthetic fiber swab with plastic shaft (not wooden)
o Insert swab into the nostril parallel to the palate. Leave the swab in place for a few seconds to
absorb secretions. An instructional video for NP swab collection can be found at
KDHE COVID-
19 webpage (www.kdheks.gov/coronavirus/).
• Label the specimen container with the patient’s name and specimen type.
• The NP swab should be placed in 2-3 mL of Viral Transport Media (VTM). If VTM is not available, liquid
Amies solution, sterile phosphate-buffered saline, or normal sterile saline is acceptable
.
• Ensure the specimen tube is tight and will not leak.
• Place NP swab into its own 95 kPa bag. Ensure that sufficient absorbent material is present in
specimen transport bags.
• Place all specimens in resealable zip-top biohazard bag.
• Store specimens at 2-8⁰C and ship overnight on ice packs as a Category B infectious substance
.
o Rapid shipping is important - specimens must be tested within 72 hours of specimen collection.
Ship overnight. Use a weekend delivery option if shipping near the weekend.
• Ship to
o Kansas Health and Environmental Laboratories
o 6810 SE Dwight St, Topeka, KS 66620
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

KDHE COVID-19 Testing Approval Form - Self Submit

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 9 April 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document