Your reference
Date of collection Time
Date sent to PHE
All requests are subject to PHE standard terms and conditions. VW-2118-03Version effective from 10 Feb -2020
Please write clearly in dark ink
SAMPLE INFORMATION
LABORATORY REQUEST
Yes No Unknown
Date of onset
OTHER COMMENTS
Immune compromised
(please specify)
Other
(please specify)
CLINICAL DETAILS/EPIDEMIOLOGICAL INFORMATION
TESTING REQUEST
SARS-CoV-2 clinical – meets clinical definition
SCOVER Surveillance – (SRF)
SCOVER Surveillance – (ICU patient)
Contact of confirmed case of 2019-nCov
Sample type
TS NS NS/TS BAL Sputum
Other
(please specify)
Hospital number
Hospital name
(if different from sender’s name)
NHS number
Surname
Forename
Sex male female
Date of birth
Patient’s postcode
Age
Patient’s HPT
Postcode
Report to be sent FAO
Contact Numbers
In Hours
Out of Hours
PATIENT/SOURCE INFORMATION
SENDER’S INFORMATION
Please tick the box if your clinical sample is post mortem
For samples for screening – please send to nearest designated testing laboratory see Guidance Note:
Testing for COVID-19 (SARS-CoV-2)- available from the designated testing laboratory
https://www.gov.uk/government/publications/wuhan-novel-coronavirus-guidance-for-clinical-diagnostic-
laboratories or bit.ly/2SafTX4
IMPORTANT: please complete all fields below to avoid delays in processing.
All samples submitted should be treated as though
the patient is infected with a Hazard Group 3 Pathogen.
All samples must be sent in accordance with Cat B
transport guidance.
Please send to the nearest designated testing laboratory,
see guidance note:
Testing for the COVID-19 (SARS-CoV-2) which is available
from the regional testing laboratory and at the link at the
top of the form.
AVAILABLE LOCAL TESTING RESULTS
An avian influenza risk assessment should be
undertaken for travellers returning from Far East
Influenza A
if Flu A positive
Influenza B
RSV
Legionella
Pos/Neg/Not tested
H1/H3/H5/H7/untypeable
Pos/Neg/Not tested
Pos/Neg/Not tested
Pos/Neg/Not tested
Clinical details:
Fever
Cough
SOB or difficulty breathing
Sore throat
Clinical evidence of pneumonia/ARDS
CXR evidence of pneumonia/ARDS
Foreign travel within 14 days of onset?
If yes, travel to which countries?
Date of return to UK
Vaccinated with current season’s Influenza vaccine
Does the patient have an underlying condition?
Community patient
Hospitalised patient
Admitted to HDU/ICU
Mechanical Ventilation
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
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