Officer Mm

SRF ID (RTPCR): * * * * * * * * * * * * *

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 Fields marked with asterisk are mandatory to be filled SECTION A – PATIENT DETAILS

A.1 TEST INITIATION DETAILS

*Sample collected first time : Yes No

If No, Patient ID :

A.2 PERSONAL DETAILS

*Patient Name: NIVETHA Father's Name:

*Age: 18 Years

*Gender:Male Female Transgender

*Occupation:Other

*Mobile Number: 6 3 6 9 0 3 9 0 4 6 *Mobile Number belongs to: Patient Family

*Nationality: India

*Present patient address: MANI SETHURAYARSTPOOVATHUR *Downloaded Aarogya Setu App: Yes No Pincode: - - - - - -

*District : THANJAVUR *State : TAMIL NADU

(These fields to be filled for all patients including foreigners) Aadhaar No. (For Indians):

* Passport No. (for Foreign Nationals):

Received COVID-19 vaccine Yes No

If yes type of vaccine

Date of Dose 1 : Dose 2 :No Date of Dose 2 :

*A.3 SPECIMEN INFORMATION FROM REFERRING AGENCY

*Specimen type Throat Swab Nasal Swab Bronchoalveolar lavage

Endotracheal

Aspirate Nasopharyngeal Swab

*Type of test RT-PCR Rapid Antigen Test (RAT)

*Collection date 23/01/2022

*Sample ID(Label) 5

If, RT-PCR test, name of lab where sample is sent for testing THMC - Thanjavur Medical College, Tamil Nadu

* Mode of Transport used to visit testing facility Public - Bus Symptomatic Asymptomatic

Contact of a lab confirmed case : Yes No

Please Note - Hospital form is required for the patients visiting OPD, IPD and Emergency and Community form is required for patients under containment zone/ Non-containment area/ Point of entry/ Testing on demand

*A.3.1 For Community

Sample collected from Non-containment Zone

Cat 4: Testing on Demand

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*A.3.2 For Hospital

Not Applicable

* Fields marked with asterisk are mandatory to be filled Please Note: Section B1 and B2 need to be filled for both Community and Hospital settings. Section B3 needs to be filled only for Hospital settings Section B- MEDICAL INFORMATION

B.1 CLINICAL SYMPTOMS AND SIGNS

Cough Loss of taste

Sore throat Diarrhoea

Fever Breathlessness

Loss of smell Other symptoms, please specify

Date of onset of First Symptom :

B.2 PRE-EXISTING MEDICAL CONDITIONS

Diabetes Over weight/ Obesity

Heart disease Hypertension

Chronic lung disease Cancer

Chronic Kidney disease Any other please specify

B.3 HOSPITALIZATION DETAILS

Not Applicable

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)

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