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
Yes No Unknown
Date of onset
CLINICAL DETAILS/EPIDEMIOLOGICAL INFORMATION
SARS-CoV-2 clinical – meets clinical deﬁnition
SCOVER Surveillance – (SRF)
SCOVER Surveillance – (ICU patient)
Contact of conﬁrmed case of 2019-nCov
TS NS NS/TS BAL Sputum
(if different from sender’s name)
Sex male female
Date of birth
Report to be sent FAO
Out of Hours
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
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
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
if Flu A positive
SOB or difﬁculty breathing
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?
Admitted to HDU/ICU
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