Fillable SUBMITTAL FORM PUBLIC HEALTH LAB TESTING FOR COVID-19

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SUBMITTAL FORM PUBLIC HEALTH LAB TESTING FOR COVID-19

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Public Health Division
Communicable Disease
County of Santa Cruz
HEALTH SERVICES AGENCY
POST OFFICE BOX 962, 1060 EMELINE AVE., SANTA CRUZ, CA 95061
TELEPHONE: (831) 454-4114 FAX: (831) 454-5049 TDD: Call 711
Pg 1 of 1
SUBMITTAL FORM PUBLIC HEALTH LAB TESTING FOR COVID-19
Instructions:
1. Once you suspect COVID-19, complete CDC PUI Form and FAX to (831) 454 – 5049 or E-Mail
HSACD@santacruzcounty.us. If after hours, call (831) 471-1170 to speak with the Health Officer for
review.
2. If you don’t hear back soon, call (831) 454-4114 to confirm receipt and find out if specimens should
be collected (if so, see instructions below).
3. If approved, Collect specimens as recommended by the CDC (nasopharyngeal & oralpharyngeal
specimens at a minimum), and include a hard copy of this form and the CDC PUI Form. Also, FAX or
E-Mail this form to the contact information in step 1.
PATIENT INFORMATION
Patient’s Name (Last, First):
DOB:
AGE:
SEX:
M F
PREGNANT?
No (or N/A) Yes, EDD:
Mailing Address (include ZIP code):
ETHNICITY:
Hispanic
Non-Hispanic
PRIMARY LANGUAGE:
English
Spanish, but speaks English?
Phone #:
Alternate Phone #:
SPECIMEN INFORMATION
Type of Specimen:
Nasopharyngeal swab
Oralpharyngeal swab
Other:_________________
Date of Specimen
Collection:
Was this patient tested for influenza test? Yes No
- If yes, the result was: Positive Negative
- If positive, was subtype identified? Flu A Flu B Not typed
PROVIDER INFORMATION
PROVIDER NAME:
PROVIDER OFFICE ADDRESS:
PROVIDER PHONE #:
PROVIDER FAX #:
RESULTS WILL BE SENT TO: SANTA CRUZ COUNTY CD UNIT AT FAX: (831) 454-5049
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SUBMITTAL FORM PUBLIC HEALTH LAB TESTING FOR COVID-19

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Completed 19 February 2021

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