SRF ID (Rapid Antigen): * * * * * * * * * * * * *

ICMR Specimen Referral Form for COVID-19 (SARS-CoV2) INTRODUCTION:

This form is for collection centres / labs to enter details of the samples being tested for Covid-19. It is mandatory to fill this form for each and every sample being tested. It is essential that the collection centres / labs exercise caution to ensure that correct information is captured in the form.

INSTRUCTIONS:

Inform the local / district / state health authorities, especially surveillance officer for further guidance Seek guidance on requirements for the clinical specimen collection and transport from nodal officer This form may be filled in and shared with the IDSP and forwarded to a lab where testing is planned Field marked with asterisk are mandatory

SECTION A – PATIENT DETAILS

A.1 TEST INITIATION DETAILS

*Doctor's Prescription : Yes No *Follow up Sample : Yes No

(If yes, attach prescription; if no, test cannot be conducted) If yes, Patient ID : 295********** A.2 PERSON DETAILS

*Patient Name: MD SHAFI AHMED KHAJA PEERAN *Age: 44 Years

*Patient in quarantine facility: Yes No *Gender:Male Female Others

*Present Village or Town: RAHEMAN COLONY HAGARGA ROAD KALBURGI *Mobile Number: 9 9 8 6 0 6 1 1 0 6

*District of present residence: KALABURAGI *Mobile number belongs to: Self Family

*State of present residence: KARNATAKA *Nationality: India

*Patient's Present Address: RAHEMAN COLONY *Downloaded Aarogya Setu App: Yes No HAGARGA ROAD KALBURGI (These fields to be filled for all patients including foreigners) Pin Code:

Aadhaar No. (For Indians):

Passport No. (for Foreign Nationals):

*A.3 SPECIMEN INFORMATION FROM REFERRING AGENCY

*Specimen type Throat Swab Nasal Swab BAL ETA Nasopharyngeal Swab

*Collection date 10/10/2020

*Sample ID(Label) 1

*A.4 PATIENT CATEGORY (PLEASE SELECT ONLY ONE)

NIC-(https://covid19cc.nic.in) Page 1 of 3 10/10/2020 2:07:14 PM Cat-A1:Routine Surveillance in Containment Zone-All Symptomatic cases, including Healthcare and frontline workers

Cat-A2:Routine Surveillance Containment Zone-All Asymptomatic cases, Direct and High Risk Contacts Cat-A3:Routine Surveillance Containment Zone-All Asymptomatic high risk individuals Cat-B4:Routine Surveillance in Non-Containment Zone-All Symptomatic cases with history of International travel in last 14 days

Cat-B5:Routine Surveillance Non-Containment Zone-All Symptomatic contacts of Laboratory confirmed cases Cat-B6:Routine Surveillance Non-Containment Zone-All Symptomatic health care and frontline workers Cat-B7:Routine Surveillance Non-Containment Zone-Symptomatic cases among returnees and migrants within 7 days of illness

Cat-B8:Routine Surveillance Non-Containment Zone-All Asymptomatic high risk contacts Cat-C9: In Hospital-All patients of Severe Acute Respiratory infection (SARI) Cat-C10:In Hospital-Symptomatic Patients presenting in a health care setting Cat-C11:In Hospital-Asymptomatic high risk patients Cat-C12:In Hospital-Asymptomatic patients undergoing surgical / non-surgical invasive procedures Cat-C13:In Hospital-Pregnant women in / near labour Cat-C14:In Hospital-Symptomatic neonats presenting with acute respiratory/ sepsis like illness Cat-C15:In Hospital-Patients presenting with atypical manifestations Cat-D16:Testing on Demand-Individuals undergoing travel to Countries/ Indian States mandating negative Covid19 test

Cat-D17: Individual who wish to get tested

NIC-(https://covid19cc.nic.in) Page 2 of 3 10/10/2020 2:07:14 PM Section B- MEDICAL INFORMATION

B.1 CLINICAL SYMPTOMS AND SIGNS

Symptoms : Yes No If No please go to B.2 section

Symptoms Yes Symptoms Yes Symptoms Yes Symptoms Yes Symptoms Yes Cough Diarrhoea Vomiting Fever at evaluation Abdominal pain Breathlessness Nausea Haemoptysis Body ache

Sore throat Chest pain Nasal discharge Sputum

Which of the above mentioned was First Symptom: Date of onset of First Symptoms: (dd/mm/yy) B.2 PRE-EXISTING MEDICAL CONDITIONS

Condition Yes Condition Yes Condition Yes Condition Yes Chronic lung disease Malignancy Heart disease Chronic liver disease Chronic renal disease Diabetes Hypertension

Immunocompromised condition: Yes No Other underlying conditions: B.3 HOSPITALIZATION DETAILS

Hospitalized : Yes No Hospital State:

Hospital ID / Number: Hospital District:

Hospitalization Date: (dd/mm/yy) Hospital Name:

B.4 REFERRING DOCTOR DETAILS

Doctor's Email ID:

*Name of the Doctor: DR GANJALKHAIR SIR Doctor's Mobile No.: Rapid Antigen Test

Testing Kit Used SD Biosensor Standard Q COVID-19 Ag Detection Kit SRF ID Submit Date : 10/10/2020

TEST RESULT (To be filled by Covid-19 testing lab facility) Date of sample receipt

(dd/mm/yy)

Sample

accepted/Rejected

Date of testing

(dd/mm/yy)

Test result

(Positive/Negative)

Repeat Sample

required (Yes/No)

Sign of the

Authority(Lab in

charge)

NIC-(https://covid19cc.nic.in) Page 3 of 3 10/10/2020 2:07:14 PM

Contact this candidate