Form 81.3 "Clinical Specimen Submission Form" - Hawaii

What Is Form 81.3?

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

Form Details:

  • Released on January 1, 2016;
  • The latest edition provided by the Hawaii Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 81.3 by clicking the link below or browse more documents and templates provided by the Hawaii Department of Health.

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Download Form 81.3 "Clinical Specimen Submission Form" - Hawaii

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State Laboratories Division
STATE LABORATORY NUMBER
HAWAII STATE DEPARTMENT OF HEALTH
2725 Waimano Home Rd
Pearl City, HI 96782
DATE RECEIVED
(PLEASE PRINT LEGIBLY)
I. PATIENT IDENTIFICATION
ORDERING/PRIMARY PHYSICIAN:
LAST NAME
FIRST NAME AND MIDDLE INITIAL
ADDRESS:
(Street,
City, Zip code)
RESIDENT ADDRESS (Physical place of residence Street, City, Zip code)
PHONE NO:
SUBMITTING LABORATORY:
PHONE NO:
ADDRESS:
(Street,
OCCUPATION
RACE
DATE OF BIRTH
SEX
City, Zip code)
PHONE NO:
CLINICAL DIAGNOSIS
DATE OF ONSET
LABORATORY EXAMINATION REQUESTED
CATEGORY OF AGENT SUSPECTED
SPECIFIC AGENT SUSPECTED
II. SPECIMEN INFORMATION
III. CLINICAL HISTORY
1. SOURCE OF SPECIMEN
4. REFERRED SPECIMEN
1. CLINICAL SIGNS AND SYMPTOMS
HUMAN
PURE ISOLATE
FEVER
OTHER (Specify): _______________________________
MIXED CULTURE
EXANTHEMA (Specify Type):
________________________________________________
__________________________________________________
OTHER (Specify): _____________________________________
RESPIRATORY SIGNS: ___________________________
DATE OF ORIGINAL CULTURE: _______________________________
2. ORIGINAL MATERIAL SUBMITTED
________________________________________________
PRIMARY ISOLATION MEDIA: _________________________________
* TYPE OF SPECIMEN: _______________________________
CENTRAL NERVOUS SYSTEM
COLLECTION SITE OF ORIGINAL SPECIMEN: ___________________
__________________________________________________
INVOLVEMENT: _________________________________
___________________________________________________________
________________________________________________
DATE OF COLLECTION: _____________________________
GASTROINTESTINAL INVOLVEMENT:
DATE OF CULTURE SUBMITTED AND TRANSPORT
TRANSPORT MEDIUM: ______________________________
________________________________________________
MEDIUM USED: _____________________________________________
__________________________________________________
________________________________________________
* SPECIFY SITE OF COLLECTION
____________________________________________________________
2. ADDITIONAL INFORMATION
SUSPECTED IDENTIFICATION: ________________________________
3. SEROLOGY SPECIMEN
____________________________________________________________
COLLECTION DATE
TRAVEL HISTORY: _________________________________
ACUTE (S1): ____________________________________
___________________________________________________
OTHER ORGANISMS FOUND: _________________________________
CONVALESCENT (S2): ___________________________
____________________________________________________________
IMMUNIZATIONS: __________________________________
S3: ____________________________________________
__________________________________________________
OTHER INFORMATION: _______________________________________
S4: ___________________________________________
____________________________________________________________
ANTIBIOTIC THERAPY: ______________________________
Other (Specify): _________________________________
____________________________________________________________
___________________________________________________
DEPARTMENT OF HEALTH USE ONLY
3. PREVIOUS LABORATORY RESULTS / OTHER
INFORMATION:
DATE OF REPORT: ____________________________
FORM 81.3 – SLD Rev 1/2016
SLD_FRM_81.3_975v1
State Laboratories Division
STATE LABORATORY NUMBER
HAWAII STATE DEPARTMENT OF HEALTH
2725 Waimano Home Rd
Pearl City, HI 96782
DATE RECEIVED
(PLEASE PRINT LEGIBLY)
I. PATIENT IDENTIFICATION
ORDERING/PRIMARY PHYSICIAN:
LAST NAME
FIRST NAME AND MIDDLE INITIAL
ADDRESS:
(Street,
City, Zip code)
RESIDENT ADDRESS (Physical place of residence Street, City, Zip code)
PHONE NO:
SUBMITTING LABORATORY:
PHONE NO:
ADDRESS:
(Street,
OCCUPATION
RACE
DATE OF BIRTH
SEX
City, Zip code)
PHONE NO:
CLINICAL DIAGNOSIS
DATE OF ONSET
LABORATORY EXAMINATION REQUESTED
CATEGORY OF AGENT SUSPECTED
SPECIFIC AGENT SUSPECTED
II. SPECIMEN INFORMATION
III. CLINICAL HISTORY
1. SOURCE OF SPECIMEN
4. REFERRED SPECIMEN
1. CLINICAL SIGNS AND SYMPTOMS
HUMAN
PURE ISOLATE
FEVER
OTHER (Specify): _______________________________
MIXED CULTURE
EXANTHEMA (Specify Type):
________________________________________________
__________________________________________________
OTHER (Specify): _____________________________________
RESPIRATORY SIGNS: ___________________________
DATE OF ORIGINAL CULTURE: _______________________________
2. ORIGINAL MATERIAL SUBMITTED
________________________________________________
PRIMARY ISOLATION MEDIA: _________________________________
* TYPE OF SPECIMEN: _______________________________
CENTRAL NERVOUS SYSTEM
COLLECTION SITE OF ORIGINAL SPECIMEN: ___________________
__________________________________________________
INVOLVEMENT: _________________________________
___________________________________________________________
________________________________________________
DATE OF COLLECTION: _____________________________
GASTROINTESTINAL INVOLVEMENT:
DATE OF CULTURE SUBMITTED AND TRANSPORT
TRANSPORT MEDIUM: ______________________________
________________________________________________
MEDIUM USED: _____________________________________________
__________________________________________________
________________________________________________
* SPECIFY SITE OF COLLECTION
____________________________________________________________
2. ADDITIONAL INFORMATION
SUSPECTED IDENTIFICATION: ________________________________
3. SEROLOGY SPECIMEN
____________________________________________________________
COLLECTION DATE
TRAVEL HISTORY: _________________________________
ACUTE (S1): ____________________________________
___________________________________________________
OTHER ORGANISMS FOUND: _________________________________
CONVALESCENT (S2): ___________________________
____________________________________________________________
IMMUNIZATIONS: __________________________________
S3: ____________________________________________
__________________________________________________
OTHER INFORMATION: _______________________________________
S4: ___________________________________________
____________________________________________________________
ANTIBIOTIC THERAPY: ______________________________
Other (Specify): _________________________________
____________________________________________________________
___________________________________________________
DEPARTMENT OF HEALTH USE ONLY
3. PREVIOUS LABORATORY RESULTS / OTHER
INFORMATION:
DATE OF REPORT: ____________________________
FORM 81.3 – SLD Rev 1/2016
SLD_FRM_81.3_975v1