"Influenza Surveillance Laboratory Submission Form" - Hawaii

Influenza Surveillance Laboratory Submission Form is a legal document that was released by the Hawaii Department of Health - a government authority operating within Hawaii.

Form Details:

  • Released on February 1, 2016;
  • The latest edition currently provided by the Hawaii Department of Health;
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Download "Influenza Surveillance Laboratory Submission Form" - Hawaii

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MEDICAL MICROBIOLOGY BRANCH
DATE RECEIVED BY STATE LABORATORY:
HAWAII STATE DEPARTMENT OF HEALTH
2725 WAIMANO HOME ROAD
PEARL CITY, HAWAII 96782
STATE DEPARTMENT OF HEALTH ACCESSION NUMBER:
SPECIMENS COLLECTED FOR INFLUENZA SURVEILLANCE ONLY
CLINICAL DIAGNOSIS: INFLUENZA LIKE ILLNESS
SPECIMEN PRIORITY IDENTIFICATION
:
NAME AND ADDRESS OF PHYSICIAN/SCHOOL/FACILITY:
[PLEASE FILL OUT COMPLETELY]
ILINET (SENTINEL) PROVIDER
ID#___________________________
YES
NO
UNK
*PATIENT HOSPITALIZED?
____/____/_____
*IF YES, HOSPITAL NAME:
_________________________________
*ARDS NOT DUE TO ANOTHER ETIOLOGY?
*X-RAY CONFIRMED PNEUMONIA?
*TRAVEL OUTSIDE HAWAII WITHIN 10 DAYS
PATIENT IDENTIFICATION:
PRIOR TO ONSET?
PATIENT
ID#______________________________________________________
*IF YES, WAS TRAVEL
NAME:________________________________________________SEX:
______
DOMESTIC OR
INTERNATIONAL?
*IF YES, CITIES, COUNTRIES & DATES:
DATE OF BIRTH (MM/DD/YY)
______/_______/_______
AGE:
_____________
___________________________________________
HAWAII RESIDENT
VISITOR FROM:
*IS PATIENT A HEALTHCARE WORKER?
CONTACT INFORMATION:
_______________________
*DOES THE PATIENT HAVE UNDERLYING
MEDICAL CONDITIONS? IF YES, PLEASE
PHONE NUMBER:
( _______ ) __________ - ___________________________
LIST:
___________________________________
ADDRESS:________________________________________________________
*IS THE PATIENT PREGNANT OR UP TO 6
CITY/STATE/ZIP:___________________________________________________
WEEKS POST-PARTUM?
WORK / SCHOOL LOCATION:
_______________________________________
*ANY UNUSUAL PRESENTATIONS OF
SUSPECT INFLUENZA INFECTION?
OCCUPATION:____________________________________________________
____________________________________
FOR NON-RESIDENTS ONLY (LOCAL CONTACT INFORMATION):
LABORATORY SPECIMEN/RAPID TESTING INFORMATION:
HOTEL
NAME/ADDRESS:___________________________________________
COLLECTION DATE (MM/DD/YY):
______/_______/_______
CITY/STATE/ZIP:___________________________________________________
SPECIMEN:
NASOPHARYNGEAL SWAB
BRONCHIAL WASH
CLINICAL SIGNS AND SYMPTOMS:
THROAT SWAB
NASAL ASPIRATE / WASH
DATE OF ONSET (MM/DD/YY):
______/_______/_______
NASAL SWAB
OTHER (SPECIFY):
SYMPTOM
_____________________
YES
NO
UNK
YES
NO
UNK
FEVER
(MAXIMUM
TEMP:__________
F)
SECTION BELOW FOR LABORATORY USE ONLY
COUGH
MUSCLE ACHES
RAPID TESTING DATE (MM/DD/YY):
______/_______/_______
TEST KIT USED:
SORE THROAT
DIARRHEA
QUICKVUE
DIRECTIGEN
MALAISE
VOMITING
BINAX
OTHER (SPECIFY):
CHILLS
HEADACHE
BD VERITOR
_____________
OTHER (SPECIFY):
RAPID TEST
RESULTS
FLU A
POS
NEG
VACCINATION AND VIRAL THERAPY HISTORY:
FLU B
POS
NEG
________________________
ACCESSION #/ LAB ID#
DID PATIENT RECEIVE SEASONAL FLU VACCINE IN THE LAST 6 MONTHS?
LABORATORY TO PERFORM INFLUENZA PCR TESTING:
YES
NO
UNK
CLH
DLS
Kaiser
SLD
OTHER: _____________
PCR TESTING DATE (MM/DD/YY):
______/_______/_______
IS PATIENT RECEIVING ANTIVIRAL MEDICATIONS?
INFLUENZA A & B RT-PCR RESULTS:
YES
NO
UNK
FLU A RNA
DETECTED
NOT DETECTED
OTHER
FLU B RNA
DETECTED
NOT DETECTED
OTHER
MEDICATION NAME:
_______________________________________________
INFLUENZA A SUBTYPING RT-PCR RESULTS:
DATE STARTED,
DOSAGE:__________________________________________
H1 RNA
DETECTED
NOT DETECTED
OTHER
H3 RNA
DETECTED
NOT DETECTED
OTHER
H5 RNA
DETECTED
NOT DETECTED
OTHER
swH1 RNA
DETECTED
NOT DETECTED
OTHER
FOR SLD USE ONLY: SPECIMEN TRANSPORTED BY
CLH
DLS
KSR
DOH (STD)
OTHER:
HDOH/ Disease Outbreak Control Division/ Influenza Surveillance Laboratory Submission Form Rev. February, 2016
MEDICAL MICROBIOLOGY BRANCH
DATE RECEIVED BY STATE LABORATORY:
HAWAII STATE DEPARTMENT OF HEALTH
2725 WAIMANO HOME ROAD
PEARL CITY, HAWAII 96782
STATE DEPARTMENT OF HEALTH ACCESSION NUMBER:
SPECIMENS COLLECTED FOR INFLUENZA SURVEILLANCE ONLY
CLINICAL DIAGNOSIS: INFLUENZA LIKE ILLNESS
SPECIMEN PRIORITY IDENTIFICATION
:
NAME AND ADDRESS OF PHYSICIAN/SCHOOL/FACILITY:
[PLEASE FILL OUT COMPLETELY]
ILINET (SENTINEL) PROVIDER
ID#___________________________
YES
NO
UNK
*PATIENT HOSPITALIZED?
____/____/_____
*IF YES, HOSPITAL NAME:
_________________________________
*ARDS NOT DUE TO ANOTHER ETIOLOGY?
*X-RAY CONFIRMED PNEUMONIA?
*TRAVEL OUTSIDE HAWAII WITHIN 10 DAYS
PATIENT IDENTIFICATION:
PRIOR TO ONSET?
PATIENT
ID#______________________________________________________
*IF YES, WAS TRAVEL
NAME:________________________________________________SEX:
______
DOMESTIC OR
INTERNATIONAL?
*IF YES, CITIES, COUNTRIES & DATES:
DATE OF BIRTH (MM/DD/YY)
______/_______/_______
AGE:
_____________
___________________________________________
HAWAII RESIDENT
VISITOR FROM:
*IS PATIENT A HEALTHCARE WORKER?
CONTACT INFORMATION:
_______________________
*DOES THE PATIENT HAVE UNDERLYING
MEDICAL CONDITIONS? IF YES, PLEASE
PHONE NUMBER:
( _______ ) __________ - ___________________________
LIST:
___________________________________
ADDRESS:________________________________________________________
*IS THE PATIENT PREGNANT OR UP TO 6
CITY/STATE/ZIP:___________________________________________________
WEEKS POST-PARTUM?
WORK / SCHOOL LOCATION:
_______________________________________
*ANY UNUSUAL PRESENTATIONS OF
SUSPECT INFLUENZA INFECTION?
OCCUPATION:____________________________________________________
____________________________________
FOR NON-RESIDENTS ONLY (LOCAL CONTACT INFORMATION):
LABORATORY SPECIMEN/RAPID TESTING INFORMATION:
HOTEL
NAME/ADDRESS:___________________________________________
COLLECTION DATE (MM/DD/YY):
______/_______/_______
CITY/STATE/ZIP:___________________________________________________
SPECIMEN:
NASOPHARYNGEAL SWAB
BRONCHIAL WASH
CLINICAL SIGNS AND SYMPTOMS:
THROAT SWAB
NASAL ASPIRATE / WASH
DATE OF ONSET (MM/DD/YY):
______/_______/_______
NASAL SWAB
OTHER (SPECIFY):
SYMPTOM
_____________________
YES
NO
UNK
YES
NO
UNK
FEVER
(MAXIMUM
TEMP:__________
F)
SECTION BELOW FOR LABORATORY USE ONLY
COUGH
MUSCLE ACHES
RAPID TESTING DATE (MM/DD/YY):
______/_______/_______
TEST KIT USED:
SORE THROAT
DIARRHEA
QUICKVUE
DIRECTIGEN
MALAISE
VOMITING
BINAX
OTHER (SPECIFY):
CHILLS
HEADACHE
BD VERITOR
_____________
OTHER (SPECIFY):
RAPID TEST
RESULTS
FLU A
POS
NEG
VACCINATION AND VIRAL THERAPY HISTORY:
FLU B
POS
NEG
________________________
ACCESSION #/ LAB ID#
DID PATIENT RECEIVE SEASONAL FLU VACCINE IN THE LAST 6 MONTHS?
LABORATORY TO PERFORM INFLUENZA PCR TESTING:
YES
NO
UNK
CLH
DLS
Kaiser
SLD
OTHER: _____________
PCR TESTING DATE (MM/DD/YY):
______/_______/_______
IS PATIENT RECEIVING ANTIVIRAL MEDICATIONS?
INFLUENZA A & B RT-PCR RESULTS:
YES
NO
UNK
FLU A RNA
DETECTED
NOT DETECTED
OTHER
FLU B RNA
DETECTED
NOT DETECTED
OTHER
MEDICATION NAME:
_______________________________________________
INFLUENZA A SUBTYPING RT-PCR RESULTS:
DATE STARTED,
DOSAGE:__________________________________________
H1 RNA
DETECTED
NOT DETECTED
OTHER
H3 RNA
DETECTED
NOT DETECTED
OTHER
H5 RNA
DETECTED
NOT DETECTED
OTHER
swH1 RNA
DETECTED
NOT DETECTED
OTHER
FOR SLD USE ONLY: SPECIMEN TRANSPORTED BY
CLH
DLS
KSR
DOH (STD)
OTHER:
HDOH/ Disease Outbreak Control Division/ Influenza Surveillance Laboratory Submission Form Rev. February, 2016
Instructions for Collection of Specimens for
Identification of Influenza and Other Respiratory Viruses
Specimen Collection Criteria:
a) Specimen collection must be within 72 hours of onset
b) Patient must have fever (temperature > 100º F oral or equivalent) AND
c) Patient must have cough OR sore throat (in the absence of a known other cause)
1. Always store viral transport medium (VTM) at room temperature. Make sure the VTM is a clear pink solution before use.
(Discard if it is cloudy or turns yellow.)
2. Use only the sterile flocked swab provided. (Do NOT use calcium alginate swabs or swabs with wooden shafts.)
3. Collect ONE nasopharyngeal swab.
4. Nasopharyngeal swab procedure (see diagram for appropriate positioning):
a) Remove swab from its wrapper.
b) Immobilize patient’s head and insert swab into a nostril back to the posterior nares.
c) Leave the swab in place for up to 10 seconds. If resistance is encountered during insertion of the swab, remove it and
attempt insertion on the opposite nostril.
d) Remove the swab slowly.
5. Break/bend the swab shaft to permit closure of vial cap and make sure screw caps are securely fastened and taped with
parafilm or masking tape to avoid leakage. Place the specimen in the same tube of viral transport media. Write the
patient's name, date of specimen collection, and specimen type (source of specimen) on the tube. Refrigerate tube
immediately.
6. Seal the specimen tube in a zip-lock bag clearly marked with a biohazard symbol. Complete enclosed "Specimen
Submission Form" and place the form in the outside pouch of the bag OR staple or tape the form to the outside of the zip-
lock bag.
7. Submit specimen to the diagnostic laboratory from which the specimen collection kit was obtained.
If you have any questions regarding the Influenza Surveillance Program or submission of specimens, please contact the
Hawaii Department of Health, Disease Investigation Branch, at 586-4586.
Sample Submission Form 2/1/2016
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