VZV SpecimenCollection Form 
UNIQUE IDENTIFIER (ASSIGNED BY CDC) 
PATIENT INFORMATION 
Name (Last, First): ______________________________________ 
Date of Birth: _____ /_____ /_____ or Age (yrs): _________ 
Sex: Male FemaleSSex:MaleFemaleex:MaleFemaleAddress: ______________________________________________ 
City/State/Zip: _________________________________________ 
Phone: _____________________ ______________________ 
PROVIDER INFORMATION 
Name: _______________________________________________ 
Institution: ____________________________________________ 
Address: _____________________________________________ 
City/State/Zip: _________________________________________City/State/Zip:_________________________________________
Phone: ____________________ Fax: _____________________ 
E-mail: _______________________________________________ 
SPECIMEN INFORMATION 
Date Collected: ______ /______ /______ 
Source of Specimen (check all that apply): 
Skin Lesion: 
Blood 
Vesicle (fluid-filled blister) 
Cerebrospinal fluid 
Papule (bump) 
Saliva 
Macule (flat lesion) 
Other (specify): 
Crust/Scab 
Other (specify): 
_________________________________ 


Reason for Specimen Submission (check all that apply): 
Suspected transmission of vaccine virus 
Suspected vaccine adverse event 
Suspected vaccine failure 
Lab confirmation 
Determine patient’s susceptibility 
Strain identification (wild type vs. vaccine strain) 
Other (specify): _______________________________ 


If an adverse event is suspected, has a VAERS report been submitted? Yes – VAERS number: __________________ 
No 
Date of Rash Onset: ______ /______ /______ 
Rash Type: 
Macules (flat) Approximate Number: __________ 
Papules (raised) Approximate Number: __________ 
Vesicles (fluid) Approximate Number: __________ 
Diagnosis: 
Varicella (Chickenpox) 
Zoster (Shingles) – Dermatome: ______________________ 
Other (specify): ____________________________________ 


Previous Chickenpox/Shingles: 
Has the patient ever had chickenpox/shingles before this illness? 
Yes chickenpox – Age: ______ No chickenpox Unknown 
Yes shingles – Age: _______ No shingles Unknown 

Macules(flat)ApproximateNumber:__________
Papules(raised)ApproximateNumber:__________
Vesicles(fluid)ApproximateNumber:__________
Varicella(Chickenpox)
Zoster(Shingles)–Dermatome:______________________
Other(specify):____________________________________

Yes chickenpox–Age:______No chickenpox Unknown  Yes shingles–Age:_______

No shingles  Yes chickenpox–Age:______  No chickenpox  Unknown  Yes shingles–Age:_______

No shingles Yes shingles–Age:_______  No shingles Medications: 

Does the patient have any underlying medical conditions? 
Yes No Unknown 
If yes, specify: ____________________________________ 
Did the patient take steroid(s) (i.e., oral =2mg/kg of 
body weight or total of =20mg/day of prednisone or 
equivalent for persons >10kg and administered for =2 
weeks) or immunosuppressant(s) during the 
month prior to rash onset? 
Yes No Unknown 

In the week before the specimen was collected, did the 
patient take oral acyclovir, famciclovir, or valacyclovir? 
Yes No Unknown 
If yes, specify: ______________________________________ 

Has the patient received varicella-containing vaccine? 
Yes No Unknown 
If yes, which vaccine: Varivax MMRV Zostavax 
Dose 1: Date: ______/______/______ Lot Number: ____________ 
Dose 2: Date: ______/______/______ Lot Number: ____________ 
Time since vaccination (years) if date unknown: _______________ 
Additional Clinical Information: ______________________ 
__________________________________________________ 
__________________________________________________ 

If yes,which vaccine:Varivax MMRV Zostavax If yes,which vaccine:Varivax MMRV Zostavax If yes,
which vaccine:Varivax MMRV Zostavax Yes chickenpox–Age:______No chickenpox Unknown
Please specify any other lab work performed: 
__________________________________________________ 
__________________________________________________ 
__________________________________________________ 
__________________________________________________ 
CS_116988 MAIL FORM AND SPECIMEN TO: CDC • National VZV Laboratory • 1600 Clifton Road, NE • MS G-18 Atlanta, GA 30333 Revised: 9/2007 
Tel: 404-639-3667 • Fax: 404-639-4056 • E-mail: vzvlab@cdc.gov 






http://www.cdc.gov/vaccines/vpd-vac/varicella/downloads/lab_form.txt