Fillable SARS-CoV-2 (Virus that causes COVID-19) Testing Requisition (Mississippi)

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SARS-CoV-2 (Virus that causes COVID-19) Testing Requisition (Mississippi)

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Mississippi Public Health Laboratory
570 East Woodrow Wilson Jackson, MS 39216
Phone: 601-576-7582 / Fax: 601-576-7720
CLIA #: 25D1096223
SARS-CoV-2 (Virus that causes COVID-19) Testing Requisition
Please make sure the information on the form is legible and complete.
SUBMITTER INFORMATION PATIENT INFORMATION
Patient ID Number PATIENT NAME (Last) First MI Suffix
Submitter (facility that will receive the final report) County of Residence Date of Birth
Street Address Address
City State Zip City State Zip Code
Phone Number Phone Number
Specimens Submitted
(Please only submit one specimen type per patient)
RACE
Nasopharyngeal swab (NP)
Oropharyngeal swab (OP)
Nasal mid-turbinate (NMT)
Anterior nares (NS) swab
Nasopharyngeal/Oropharyngeal combined
swabs (NP/OP)
American Indian/Alaska Native
Asian
Black
Pacific Islander/ Hawaiian
White/ Caucasian
Other
Test Requested:
ETHNICITY SEX
SARS Coronavirus 2 Real-Time RT-PCR
Hispanic or Latino
Non-Hispanic or Latino
Male
Female
Date of Collection:
C. Required Epidemiological Information. Answer ALL of the below questions.
1. Is this the patient’s first COVID-19 test? No Yes Unknown
2. Is the patient employed in healthcare? No Yes Unknown
3. Is the patient symptomatic as defined by CDC? No Yes Unknown
If yes, what was the Date of Symptom Onset ___/_____/____ ( mm/dd/yy)
If yes, mark all symptoms: Fever Cough Shortness of Breath
4. Is the patient hospitalized? No Yes Unknown
5. Is the patient in the ICU? No Yes Unknown
6. Is the patient a Resident in a congregate care setting (i.e. nursing homes, residential care for people with intellectual
and developmental disabilities, psychiatric treatment facilities, group homes, board and care homes, homeless shelter,
foster care or other setting): No Yes Unknown
7.Is the patient pregnant? No Yes Unknown
8. Is the patient a contact to a known COVID-19 case? No Yes Unknown
9. Is the patient associated with a known MSDH-confirmed outbreak? No Yes Unknown
10. Is this patient associated with a health-care acquired infection? No Yes Unknown
Mississippi State Department of Health 6/12/20 Revision Form 1198
Instructions for Form 1198, SARS-CoV-2 (Virus that causes COVID-19) Testing Requisition
Purpose
To collect submitter information, patient demographics and specimen information for isolates submitted for SARS-
CoV-2 (Virus that causes COVID-19) testing.
Instructions:
Submitter Information- Left hand side of requisition
Record all requested information
Patient ID Number: Enter the submitter’s patient identification number.
Submitter Name: Enter the submitting facility’s full name.
Street Address: Enter the submitting facility’s street address
City: Enter the submitting facility’s city
State: Enter the submitting facility’s state
Zip: Enter the submitting facility’s zip code
Phone Number: Enter the submitting facility’s phone number
Contact Name: Enter the name of the submitting facility’s contact if applicable
Contact: Enter the phone number of the submitting facility’s contact if applicable
Patient Information – Right hand of requisition
Patient Name- Enter the patient's LAST NAME, FIRST NAME AND MIDDLE INITIAL
in sequence. The spelling of the name on the laboratory slip and the specimen
container/tube must be identical. Name listed must be legal name; DO NOT use nicknames.
County of Residence- Enter the county where the patient currently resides (Hinds, Rankin, etc).
Date of Birth- Provide in MM/DD/YY format.
Address - Enter the complete address where the patient currently resides.
City - Enter the name of the city in which the patient resides.
State - Enter the state in which the patient resides
Zip Code - Enter the Zip Code of the patient's address.
Phone Number – Enter patient’s telephone number including area code.
Specimen Type: Submit a NP swab and an OP swab for each patient. If patient has a productive cough, submit one
Lower Respiratory Specimen in addition to NP and OP swabs. Provide the Date of collection in MM/DD/YY format
Test Requested: Check the box by the appropriate test requested.
Race – Check the box associated with the patient's race
Ethnicity- Check the appropriate box
Gender- Check the appropriate box (male or female)
Required Epidemiological Information: Respond Yes or No to all questions. Provide all applicable information
requested.
Office Mechanics and Filing – This form must accompany each patient for whom specimens are submitted to the
MSDH Laboratory. A copy should be retained by the submitter as documentation of submission. Test results will be
reported via computer generated report and forwarded to the submitter.
Retention Period – The MSDH Laboratory will retain the original form in accordance with Clinical Laboratory
Improvement Amendments (CLIA) regulations.
Mississippi State Department of Health 6/12/20 Revision Form 1198
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SARS-CoV-2 (Virus that causes COVID-19) Testing Requisition (Mississippi)

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Completed 30 March 2021

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