Form OL-15C "Reportable Laboratory Findings" - Connecticut

What Is Form OL-15C?

This is a legal form that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 11, 2020;
  • The latest edition provided by the Connecticut State Department of Public Health;
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Download Form OL-15C "Reportable Laboratory Findings" - Connecticut

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Connecticut Department of Public Health
Reportable Laboratory Findings
410 Capitol Avenue, MS #11FDS
Diseases Relating to Public Health - Form OL-15C
P.O. Box 340308
For information or to order forms call (860) 509-7994.
(rev. 09/11/2020)
Hartford, CT 06134-0308
Patient Last Name:
First:
D.O.B.
Age:
Street Address:
City:
State/Zip Code:
Gender:  Male  Female  Other specify:
Hispanic/Latino:  Yes  No  Unk.
Patient Phone:
Race:  White
 Black/African Amer.
 Asian
 Amer. Indian/Alaska Nat.
 Nat. Hawaiian/Other Pacific Islander
 Other specify:
 Unknown
If patient resides in a LTC facility please check:  Yes
Occupation:
Name and address of workplace:
Attending Physician Last Name:
First:
Address:
Phone:
Person Reporting:
Specimen collection date:
Lab Phone:
Date laboratory finding reported to physician:
Submitting Laboratory: (name/address or label)
Date OL-15C completed:
Hospital Chart No:
Lab Specimen No:
Source/Type specimen:
 Yes
 No
Submitted to state lab: (see reverse)
1
 Anaplasma phagocytophilum by PCR only
 Legionella
_________________________________________
spp
 Babesia
 IFA
 Culture
 DFA
 Ag positive
 PCR
IgM
IgG
(titer)
(titer)
 Blood smear
 PCR
 Other
 Four-fold serologic change
(titers)
 microti
 divergens
 duncani
 Unspeciated
 Listeria monocytogenes
1
 Culture
 PCR
 Bordetella pertussis
 Mercury poisoning
(titer)
 Urine ≥ 35 µg/g creatinine
 Culture
1
 Non-pertussis Bordetella
1
µg/g
(specify)
 Blood ≥ 15 µg/L
 DFA
 PCR
µg/L
 Mumps virus
12
 PCR
 Borrelia burgdorferi
2
(titer)
 Mycobacterium leprae
 Borrelia miyamotoi
 Mycobacterium tuberculosis Related Testing
1
 California group virus
3
spp
 Positive
 Negative
AFB Smear
3
 Campylobacter
 Culture  PCR  EIA
spp
 Rare
 Few
 Numerous
If positive
 Candida auris [report samples from all sites]
1
 Positive
 Negative
 Indeterminate
NAAT
 Candida spp, [blood isolates only]:
1,3
Culture  Mycobacterium tuberculosis
 Carbapenem-resistant Acinetobacter baumannii (CRAB)
1,4
 Non-TB mycobacterium
(specify M.)
1,3,4
 Neisseria gonorrhoeae
Carbapenem-resistant Enterobacteriaceae (CRE)
(test type)
 Neisseria meningitidis, invasive
1,4
Genus
spp
 Carboxyhemoglobin > 5%
2
 Culture
 Other
% COHb
 Chikungunya virus
 Neonatal bacterial sepsis
3,13
spp
 Chlamydia trachomatis
 Plasmodium
1,3
spp
(test type)
 Poliovirus
5
 Clostridium difficile
 Powassan virus
 Corynebacterium diphtheria
1
 Rabies virus
 Cryptosporidium spp
3
 PCR  DFA  EIA
 IgG ≥1:128 only  Culture
 Rickettsia rickettsii
 PCR
 Microscopy  Other:
2
 Respiratory syncytial virus
 Cyclospora spp
3
12
 Rubella virus
(titer)
 PCR
 Microscopy
 Other:
 Rubeola virus (Measles)
12
 PCR
(titer)
 Dengue virus
 St. Louis encephalitis virus
 Eastern equine encephalitis virus
1,3
 Salmonella
 Culture  PCR
(serogroup & type)
 IgG ≥1:128 only  Culture
 Ehrlichia chaffeensis
 PCR
 SARS-CoV
1
 IgM/IgG
 Enterotoxigenic Escherichia coli (ETEC)  Culture
 PCR
 PCR
 Other
(specimen)
 Escherichia coli O157
1
 Culture
 PCR
 SARS-CoV-2
 PCR
 Antigen
 Giardia
3
spp
 Positive
 Negative
 Group A Streptococcus, invasive
1,4
 Culture  Other
 Shiga toxin
1
 Stx1
 Stx2
 Type Unknown
 Group B Streptococcus, invasive
1,4
 Culture  Other
 PCR
 EIA
 Haemophilus ducreyi
 Shigella
1,3
 Culture  PCR
(serogroup/spp)
 Staphylococcus aureus, invasive
4
 Culture
 Other
 Haemophilus influenzae, invasive
1,4
 Culture  Other
__________
 methicillin-resistant
 methicillin-sensitive
 Hepatitis A virus (HAV):  IgM anti-HAV
6
 NAAT Positive
6
 Staphylococcus aureus, vancomycin MIC ≥ 4 µg/mL
1
 Not Done
ALT
Total Bilirubin
MIC to vancomycin
µg/mL
 Hepatitis B
 Positive
 Negative
7
HBsAg
 Staphylococcus epidermidis, vancomycin MIC ≥ 32 µg/mL
1
 IgM anti-HBc
 HBeAg
2
 HBV DNA
2
MIC to vancomycin
µg/mL
7
 Positive
 Negative
anti-HBs
(titer)
 Streptococcus pneumoniae
 Hepatitis C virus (HCV)
8
 Antibody
 Culture
1,4
 Urine antigen
 Other
4
 PCR/NAAT/RNA
 Genotype:
 Treponema pallidum
 Herpes simplex virus (infants ≤ 60 days of age)
 RPR
 FTA
 EIA
(titer)
 Culture
 PCR
 IFA
 Ag detection
 VDRL
 TPPA
(titer)
9
 HIV Related Testing
(report only to the State)
 Trichinella
 Detectable Screen
(IA)
 Varicella-zoster virus, acute
9
 Culture
 PCR
 DFA
 Other
Antibody Confirmation
(WB/IFA/Type-diff)
HIV 1  Positive  Negative/Ind
HIV 2  Positive  Negative/Ind
1,3
 Vibrio
 Culture  PCR
spp
 HIV NAAT (or qualitative RNA)  Detectable
 Not Detectable
 West Nile virus
9
 HIV Viral Load (all results)
 Yellow fever virus
copies/mL
 Yersinia, not pestis
1,3
 Culture  PCR
 HIV genotype
9
spp
 Zika virus
 CD4 count:
9
cells/uL;
%
14
BIOTERRORISM at first clinical suspicion
 HPV
10
(report only to the State)
 Bacillus anthracis
1
 Brucella
1
spp
 CIN2
 CIN3
 AIS
Biopsy proven
 Burkholderia mallei
1
 Burkholderia pseudomallei
1
or their equivalent, (specify)
 Clostridium botulinum
 Coxiella burnetii
 Influenza virus
 Rapid antigen
2
 RT-PCR
(report only to the State)
 Francisella tularensis
 Ricin
 Type A
 Type B
 Type Unknown
 Staphylococcus aureus-enterotoxin B
 Subtype:
 Variola virus
1
 Lead poisoning
(blood lead ≥10 µg/dL <48 hrs; 0-9 µg/dL monthly)
11
 Venezuelan equine encephalitis virus  Yersinia pestis
1
 Finger stick lead level
µg/dL
 Viral agents of hemorrhagic fevers
 Venous lead level
µg/dL
or ovary), or other normally sterile site including
sequence) and all CD4 results are only reportable
1.
Send isolate/specimen to DPH Laboratory. Send
muscle. For CRE and CRAB, also include urine or
by electronic file.
laboratory report (electronic or paper) on first identification
sputum; for CRAB also include wounds.
of an organism. For CRE/CRAB, send laboratory report if
10. Upon request from the DPH, send fixed tissue
carbapenem resistance is suggested by laboratory
5.
Upon request from the DPH, report all C. difficile
from the diagnostic specimen for HPV typing.
antimicrobial testing. For GBS, send isolate for cases <1
positive stool samples.
11. Report results > 10 µg/dL within 48 hours
year of age. For Salmonella, Shigella, Vibrio, and Yersinia,
to the Local Health Department and DPH; submit
6.
Report peak ALT and Total Bilirubin results if
(not pestis) tested by non-culture methods, send isolate if
ALL lead results at least monthly to DPH only.
conducted within one week of HAV positive test, if
available; send stool specimen if no isolate available. For
available. Otherwise, check “Not Done”.
12. Report all IgM positive titers, only report IgG titers
Shiga toxin-related disease, send positive broth or stool
considered significant by laboratory performing
7.
Negative HBsAg and all anti-HBs results only
specimen. For Legionella send only isolates.
reportable for children ≤ 2 years old.
the test.
2.
Only laboratories with electronic file reporting are required
13. Report all bacterial isolates from blood or CSF
8.
Report positive Antibody, and all RNA and Genotype
to report positive results.
from infants ≤ 72 hours of age.
results. Negative RNA results only reportable by
3.
Specify species/serogroup/serotype.
electronic reporting.
14. Call the DPH, weekdays 860-509-7994; evenings,
4.
Sterile site: sterile fluids (blood, CSF, pericardial, pleural,
weekends, and holidays 860-509-8000.
9.
Report all HIV antibody, antigen, viral load, and
peritoneal, joint, or vitreous), bone, internal body site
qualitative NAAT results. HIV genotype (DNA
(lymph node, brain, heart, liver, spleen, kidney, pancreas,
Connecticut Department of Public Health
Reportable Laboratory Findings
410 Capitol Avenue, MS #11FDS
Diseases Relating to Public Health - Form OL-15C
P.O. Box 340308
For information or to order forms call (860) 509-7994.
(rev. 09/11/2020)
Hartford, CT 06134-0308
Patient Last Name:
First:
D.O.B.
Age:
Street Address:
City:
State/Zip Code:
Gender:  Male  Female  Other specify:
Hispanic/Latino:  Yes  No  Unk.
Patient Phone:
Race:  White
 Black/African Amer.
 Asian
 Amer. Indian/Alaska Nat.
 Nat. Hawaiian/Other Pacific Islander
 Other specify:
 Unknown
If patient resides in a LTC facility please check:  Yes
Occupation:
Name and address of workplace:
Attending Physician Last Name:
First:
Address:
Phone:
Person Reporting:
Specimen collection date:
Lab Phone:
Date laboratory finding reported to physician:
Submitting Laboratory: (name/address or label)
Date OL-15C completed:
Hospital Chart No:
Lab Specimen No:
Source/Type specimen:
 Yes
 No
Submitted to state lab: (see reverse)
1
 Anaplasma phagocytophilum by PCR only
 Legionella
_________________________________________
spp
 Babesia
 IFA
 Culture
 DFA
 Ag positive
 PCR
IgM
IgG
(titer)
(titer)
 Blood smear
 PCR
 Other
 Four-fold serologic change
(titers)
 microti
 divergens
 duncani
 Unspeciated
 Listeria monocytogenes
1
 Culture
 PCR
 Bordetella pertussis
 Mercury poisoning
(titer)
 Urine ≥ 35 µg/g creatinine
 Culture
1
 Non-pertussis Bordetella
1
µg/g
(specify)
 Blood ≥ 15 µg/L
 DFA
 PCR
µg/L
 Mumps virus
12
 PCR
 Borrelia burgdorferi
2
(titer)
 Mycobacterium leprae
 Borrelia miyamotoi
 Mycobacterium tuberculosis Related Testing
1
 California group virus
3
spp
 Positive
 Negative
AFB Smear
3
 Campylobacter
 Culture  PCR  EIA
spp
 Rare
 Few
 Numerous
If positive
 Candida auris [report samples from all sites]
1
 Positive
 Negative
 Indeterminate
NAAT
 Candida spp, [blood isolates only]:
1,3
Culture  Mycobacterium tuberculosis
 Carbapenem-resistant Acinetobacter baumannii (CRAB)
1,4
 Non-TB mycobacterium
(specify M.)
1,3,4
 Neisseria gonorrhoeae
Carbapenem-resistant Enterobacteriaceae (CRE)
(test type)
 Neisseria meningitidis, invasive
1,4
Genus
spp
 Carboxyhemoglobin > 5%
2
 Culture
 Other
% COHb
 Chikungunya virus
 Neonatal bacterial sepsis
3,13
spp
 Chlamydia trachomatis
 Plasmodium
1,3
spp
(test type)
 Poliovirus
5
 Clostridium difficile
 Powassan virus
 Corynebacterium diphtheria
1
 Rabies virus
 Cryptosporidium spp
3
 PCR  DFA  EIA
 IgG ≥1:128 only  Culture
 Rickettsia rickettsii
 PCR
 Microscopy  Other:
2
 Respiratory syncytial virus
 Cyclospora spp
3
12
 Rubella virus
(titer)
 PCR
 Microscopy
 Other:
 Rubeola virus (Measles)
12
 PCR
(titer)
 Dengue virus
 St. Louis encephalitis virus
 Eastern equine encephalitis virus
1,3
 Salmonella
 Culture  PCR
(serogroup & type)
 IgG ≥1:128 only  Culture
 Ehrlichia chaffeensis
 PCR
 SARS-CoV
1
 IgM/IgG
 Enterotoxigenic Escherichia coli (ETEC)  Culture
 PCR
 PCR
 Other
(specimen)
 Escherichia coli O157
1
 Culture
 PCR
 SARS-CoV-2
 PCR
 Antigen
 Giardia
3
spp
 Positive
 Negative
 Group A Streptococcus, invasive
1,4
 Culture  Other
 Shiga toxin
1
 Stx1
 Stx2
 Type Unknown
 Group B Streptococcus, invasive
1,4
 Culture  Other
 PCR
 EIA
 Haemophilus ducreyi
 Shigella
1,3
 Culture  PCR
(serogroup/spp)
 Staphylococcus aureus, invasive
4
 Culture
 Other
 Haemophilus influenzae, invasive
1,4
 Culture  Other
__________
 methicillin-resistant
 methicillin-sensitive
 Hepatitis A virus (HAV):  IgM anti-HAV
6
 NAAT Positive
6
 Staphylococcus aureus, vancomycin MIC ≥ 4 µg/mL
1
 Not Done
ALT
Total Bilirubin
MIC to vancomycin
µg/mL
 Hepatitis B
 Positive
 Negative
7
HBsAg
 Staphylococcus epidermidis, vancomycin MIC ≥ 32 µg/mL
1
 IgM anti-HBc
 HBeAg
2
 HBV DNA
2
MIC to vancomycin
µg/mL
7
 Positive
 Negative
anti-HBs
(titer)
 Streptococcus pneumoniae
 Hepatitis C virus (HCV)
8
 Antibody
 Culture
1,4
 Urine antigen
 Other
4
 PCR/NAAT/RNA
 Genotype:
 Treponema pallidum
 Herpes simplex virus (infants ≤ 60 days of age)
 RPR
 FTA
 EIA
(titer)
 Culture
 PCR
 IFA
 Ag detection
 VDRL
 TPPA
(titer)
9
 HIV Related Testing
(report only to the State)
 Trichinella
 Detectable Screen
(IA)
 Varicella-zoster virus, acute
9
 Culture
 PCR
 DFA
 Other
Antibody Confirmation
(WB/IFA/Type-diff)
HIV 1  Positive  Negative/Ind
HIV 2  Positive  Negative/Ind
1,3
 Vibrio
 Culture  PCR
spp
 HIV NAAT (or qualitative RNA)  Detectable
 Not Detectable
 West Nile virus
9
 HIV Viral Load (all results)
 Yellow fever virus
copies/mL
 Yersinia, not pestis
1,3
 Culture  PCR
 HIV genotype
9
spp
 Zika virus
 CD4 count:
9
cells/uL;
%
14
BIOTERRORISM at first clinical suspicion
 HPV
10
(report only to the State)
 Bacillus anthracis
1
 Brucella
1
spp
 CIN2
 CIN3
 AIS
Biopsy proven
 Burkholderia mallei
1
 Burkholderia pseudomallei
1
or their equivalent, (specify)
 Clostridium botulinum
 Coxiella burnetii
 Influenza virus
 Rapid antigen
2
 RT-PCR
(report only to the State)
 Francisella tularensis
 Ricin
 Type A
 Type B
 Type Unknown
 Staphylococcus aureus-enterotoxin B
 Subtype:
 Variola virus
1
 Lead poisoning
(blood lead ≥10 µg/dL <48 hrs; 0-9 µg/dL monthly)
11
 Venezuelan equine encephalitis virus  Yersinia pestis
1
 Finger stick lead level
µg/dL
 Viral agents of hemorrhagic fevers
 Venous lead level
µg/dL
or ovary), or other normally sterile site including
sequence) and all CD4 results are only reportable
1.
Send isolate/specimen to DPH Laboratory. Send
muscle. For CRE and CRAB, also include urine or
by electronic file.
laboratory report (electronic or paper) on first identification
sputum; for CRAB also include wounds.
of an organism. For CRE/CRAB, send laboratory report if
10. Upon request from the DPH, send fixed tissue
carbapenem resistance is suggested by laboratory
5.
Upon request from the DPH, report all C. difficile
from the diagnostic specimen for HPV typing.
antimicrobial testing. For GBS, send isolate for cases <1
positive stool samples.
11. Report results > 10 µg/dL within 48 hours
year of age. For Salmonella, Shigella, Vibrio, and Yersinia,
to the Local Health Department and DPH; submit
6.
Report peak ALT and Total Bilirubin results if
(not pestis) tested by non-culture methods, send isolate if
ALL lead results at least monthly to DPH only.
conducted within one week of HAV positive test, if
available; send stool specimen if no isolate available. For
available. Otherwise, check “Not Done”.
12. Report all IgM positive titers, only report IgG titers
Shiga toxin-related disease, send positive broth or stool
considered significant by laboratory performing
7.
Negative HBsAg and all anti-HBs results only
specimen. For Legionella send only isolates.
reportable for children ≤ 2 years old.
the test.
2.
Only laboratories with electronic file reporting are required
13. Report all bacterial isolates from blood or CSF
8.
Report positive Antibody, and all RNA and Genotype
to report positive results.
from infants ≤ 72 hours of age.
results. Negative RNA results only reportable by
3.
Specify species/serogroup/serotype.
electronic reporting.
14. Call the DPH, weekdays 860-509-7994; evenings,
4.
Sterile site: sterile fluids (blood, CSF, pericardial, pleural,
weekends, and holidays 860-509-8000.
9.
Report all HIV antibody, antigen, viral load, and
peritoneal, joint, or vitreous), bone, internal body site
qualitative NAAT results. HIV genotype (DNA
(lymph node, brain, heart, liver, spleen, kidney, pancreas,
Pursuant to Connecticut General Statutes (CGS) and to the Regulations of Connecticut State
Agencies Public Health Code (PHC), the requested information is required to be provided to the
Department of Public Health (DPH). This form must be completely filled in by the primary laboratory.
PHC Section 19a-36-A2. List of reportable diseases and laboratory findings
An annual list of the laboratory reportable significant findings will be prepared and furnished to
directors of clinical laboratories licensed, registered, or approved by the DPH. Please refer to the
current list when reporting findings since the list will be reviewed annually and revised when
necessary.
PHC Section 19a-36-A3
Persons required to report reportable diseases and laboratory findings.
CGS Section 19a-215
Commissioner’s lists of reportable diseases, emergency illnesses and health conditions
and reportable laboratory findings. Reporting requirements. Confidentiality. Fines.
The director of a laboratory that identifies a reportable laboratory finding must report such findings
within forty-eight (48) hours to the local director of health of the town in which the affected person
normally resides, or, in the absence of such information, of the town from which the specimen
originated, and to the DPH on forms provided by the DPH or electronically in a format approved by the
DPH Commissioner. The DPH makes reported case information available to the local director of
health.
PHC Section 19a-36-A4
Content of report and reporting of reportable diseases and laboratory findings.
Each report must include:
1. full name, address, date of birth, age, gender, race/ethnicity, and occupation of person affected ;
2. full name, address and phone number of the attending physician;
3. identity of the infectious agent or other reportable laboratory findings, and date of collection;
4. method of identification.
Reports must be mailed in envelopes marked “CONFIDENTIAL” within 48 hours of identifying the
finding to the:
1. Local Director of Health of town in which the patient resides
(Canary copy)
AND
2. Connecticut Department of Public Health
(White copy)
410 Capitol Avenue, MS#11FDS
P.O. Box 340308
Hartford, CT 06134-0308
(Retain Pink copy for patient’s medical record)
PHC Section 19a-36-A3(b)(1)
Persons required to report reportable diseases and laboratory findings.
When a laboratory identifies or presumptively identifies a significant isolate or other finding that
requires confirmation by the laboratory as required in the annual list, the director must submit the
isolate or specimen from which the finding was made to the DPH’s laboratory division.
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) GUIDELINES
Pursuant to Connecticut General Statutes (CGS) §19a-2a and §19a-215 and to the Regulations of
Connecticut State Agencies Public Health Code (PHC) sections 19a-36-A3 and 19a-36-A4 as cited
above, the requested information is required to be provided to the Department of Public Health.
Please note that CGS §52-146o(b)(1) authorizes the release of these records to the Department
without the patient's consent. Additionally, the federal Privacy Regulations of the Health Insurance
Portability and Accountability Act of 1996 (HIPAA) also authorize you, as a provider, to release this
information without an authorization, consent, release, opportunity to object by the patient, as
information (i) required by law to be disclosed [HIPAA Privacy regulation 45 CFR §164.512(a)] and (ii)
as part of the Department’s public health activities [HIPAA Privacy regulation, 45 CFR
§164.512(b)(1)(i)]. The requested information is what is minimally necessary to achieve the purpose of
the disclosure, and you may rely upon this representation in releasing the requested information,
pursuant to 45 CFR §164.514(d)(3)(iii)(A) of the HIPAA Privacy regulations.
(
rev. 03/24/2020)
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