Arboviral Lab Submission Form - Illinois

This Illinois-specific printable "Arboviral Lab Submission Form" is a part of the legal paperwork issued by the Illinois Department of Public Health.

Download the up-to-date PDF by clicking the link below and mail it as per the guidelines provided by the department.

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Arboviral Lab Submission Form
Submitter Information
Authorization Number:
Submitter Phone Number:
Submitter Fax Number:
Submitting Hospital/Clinic/Laboratory Name:
Submitter Mailing Address: (Please include apartment / suite number)
City
State
Zip Code
Physician Name:
Patient Information
Patient Name: (First, Middle, Last)
Date of Birth:
Patient Address: (Please include apartment / suite number)
Medicaid Recipient ID:
City
State
Zip Code
Male
Female
Sex:
Ethnicity:
Hispanic
Non-Hispanic
Race:
White
African American/Black
Native American
Asian/Pacific Islander
Other/Unknown
Test Request Information
Specimen Collection Date:
Symptom Onset Date:
Specimen Source:
Serum
Tissue
Other (Specify)
Spinal Fluid
Urine
Amniotic Fluid
Test Requested:
Zika
Chikungunya
Dengue
West Nile Virus
St. Louis Encephalitis
California Encephalitis
Other
(Specify)
Pregnant:
Yes
No
Disease Stage:
Acute
Convalescent
Hospitalized:
Yes
No
Clinical Symptoms: (mark all that apply):
Fever
Headache
Stiff Neck
Change in Consciousness
Lethargy
Coma
Rash
Joint Pain
Conjunctivitis
Other
(Specify)
Patient Travel and Epi Information
Travel Dates:
to
State/City/Country of Exposure:
Travel Dates:
to
State/City/Country of Exposure:
Epi Comments:
(If testing for Zika and
exposure was sexual
add details here)
*
* Include partners travel history with departure and return dates, date of unprotected sex and symptom onset date.
Lab Use Only
Bar Code Area Below
Please provide all requested information. Failure to complete this form entirely may result in testing delays.
Print Form
Print Form
Arboviral Lab Submission Form
Submitter Information
Authorization Number:
Submitter Phone Number:
Submitter Fax Number:
Submitting Hospital/Clinic/Laboratory Name:
Submitter Mailing Address: (Please include apartment / suite number)
City
State
Zip Code
Physician Name:
Patient Information
Patient Name: (First, Middle, Last)
Date of Birth:
Patient Address: (Please include apartment / suite number)
Medicaid Recipient ID:
City
State
Zip Code
Male
Female
Sex:
Ethnicity:
Hispanic
Non-Hispanic
Race:
White
African American/Black
Native American
Asian/Pacific Islander
Other/Unknown
Test Request Information
Specimen Collection Date:
Symptom Onset Date:
Specimen Source:
Serum
Tissue
Other (Specify)
Spinal Fluid
Urine
Amniotic Fluid
Test Requested:
Zika
Chikungunya
Dengue
West Nile Virus
St. Louis Encephalitis
California Encephalitis
Other
(Specify)
Pregnant:
Yes
No
Disease Stage:
Acute
Convalescent
Hospitalized:
Yes
No
Clinical Symptoms: (mark all that apply):
Fever
Headache
Stiff Neck
Change in Consciousness
Lethargy
Coma
Rash
Joint Pain
Conjunctivitis
Other
(Specify)
Patient Travel and Epi Information
Travel Dates:
to
State/City/Country of Exposure:
Travel Dates:
to
State/City/Country of Exposure:
Epi Comments:
(If testing for Zika and
exposure was sexual
add details here)
*
* Include partners travel history with departure and return dates, date of unprotected sex and symptom onset date.
Lab Use Only
Bar Code Area Below
Please provide all requested information. Failure to complete this form entirely may result in testing delays.
Print Form

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