Technical: Specimen Submission: Surveillance

National Surveillance Laboratory Specimen Form
for Possible Cases of
Hantaviral Pulmonary Syndrome

Diagnostic Specimen Submission Form

CASE-PATIENT IDENTIFICATION NUMBER:

-FIPS-

-Year-

Case-Patient Name:

______________________________	______________________________	_____
Last	First	MI

State Health Department Identifying Information:

Date Specimen(s) Received by State: ___/___/___
State Health Department Lab Submitting Specimen(s):	______________________________
Name of State Lab Person Shipping Specimen(s):	______________________________
State Health Department Dept Laboratory Phone Number:	(_____)__________-__________
Hospital Submitting Specimen(s):	______________________________

Specimen(s) List: (circle specimen type)

1) Specimen ID Number: _______________

Date Collected: ___/___/___

1 Serum
2 Tissue	A Paraffin	B Formalin	C Fresh frozen
3 Blood Clot

2) Specimen ID Number: _______________

Date Collected: ___/___/___

1 Serum
2 Tissue	A Paraffin	B Formalin	C Fresh frozen
3 Blood Clot

3) Specimen ID Number: _______________

Date Collected: ___/___/___

1 Serum
2 Tissue	A Paraffin	B Formalin	C Fresh frozen
3 Blood Clot

4) Specimen ID Number: _______________

Date Collected: ___/___/___

1 Serum
2 Tissue	A Paraffin	B Formalin	C Fresh frozen
3 Blood Clot

LABEL ALL SPECIMENS WITH:

1) First and Last Name of Case-Patient

2) Case-Patient ID Number

3) State Laboratory Specimen ID Number

4) The Date the Specimen was Collected

5) Type of Specimen (e.g., lung, liver, heart, serum, etc.

On Outside of the Box Label How Specimen Should be Stored (i.e. refrigerate, frozen, do not refrigerate)

*Please send Case Report Form with this form and specimen(s).

CDC-Revised October, 1996

[Back to Specimen Submission Guidelines]

Special Pathogens Branch
Division of Viral and Rickettsial Diseases
National Center for Infectious Diseases
The Centers for Disease Control and Prevention (CDC)
U.S. Department of Health and Human Services