Special/atypical bacteriology

1. Last Name
First Name
DO NOT WRITE IN THIS SPACE
N.C. Department of Health and Human Services State Laboratory of Public Health
2. Patient Number
Submitter Laboratory/Medical Record #: _____________________
3. Address
_ t_e_ _o_f
PLEASE GIVE ALL
Month Day Year
INFORMATION REQUESTED
5. Race  1. White  2. Black  3. American Indian  4. Asian
5. Native Hawaiian/Pacifi c Islander  6. Unknown
SPECIMEN TYPE:  ISOLATED ORGANISM**
6. Hispanic or Latino Origin:  1. Yes  2. No  3. Unknown
7. Sex 1. Male  2. Female
8. Co. of Residence
9. Medicaid Client Yes
If yes, enter #  No
 GC  N. MENINGITIDIS GROUP  H. INFLUENZAE TYPE  BORDETELLA PCR  BORDETELLA CULTURE  LEGIONELLA DFA  LEGIONELLA CULTURE  REFERENCE ID** **Describe organism, including biochemical reactions Federal Tax No. _______________________________________ _______________________________________________________________ _______________________________________________________________
_______________________________________________________________
SPECIMEN SOURCE:
 BLOOD  CSF  URINE  SPUTUM  NP  BRONCH WASH BRONCH LAVAGE  BRONCH BRUSH  THROAT  STERILE BODY FLUID  WOUND–SITE ________________________  GENITAL–SITE____________  OTHER__________________________ SPECIAL/ATYPICAL BACTERIOLOGY
LABORATORY REPORT (DO NOT WRITE BELOW)
IDENTIFICATION
DATE REPORTED:
 DIRECT FA STAIN FOR _______________________________________  POSITIVE  NEGATIVE (DFA STAIN IS A PRESUMPTIVE TEST) PLEASE PROVIDE THE FOLLOWING CLINICAL OR EPIDEMIOLOGIC INFORMATION
ANY ASSOCIATED ILLNESS____________________________________________________ DATE OF ONSET ______________________________________ PERTINENT CLINICAL FINDINGS________________________________________________ SYMPTOMS __________________________________________ PREVIOUS LABORATORY RESULTS_____________________________________________ __________________________________________ SINGLE CASE  SPORADIC  CONTACT  EPIDEMIC  CARRIER  ANIMAL CONTACT __________________ FOREIGN OR DOMESTIC TRAVEL? WHERE? _____________________________ WHEN? (WITHIN LAST YEAR ) ________________________________ OTHER ____________________________________________________________________________________________________________________________ INSTRUCTIONS
PURPOSE: Isolation, identifi cation, confi rmation, further studies of human disease-producing aerobic bacteria.
PREPARATION: Collect specimen following instructions in SCOPE, using recommended collection kits. Label each specimen tube, subculture, or smear with patient's name and date of birth. Fill out this form and send in appropriate mailer with the specimen to State Laboratory of Public Health.
Place form in outer container. Do not send without label (patient name) on specimen or without form. Forms must be printed from website at http://
PREPARATION OF FORM: Left Upper Portion of Form. Item 1. Enter patient's name, last name fi rst, fi rst name, and middle initial or maiden name initial, if female. Item 2. Enter patient number (SSN or other unique number). Item 3. Enter patient's home address on lines immediately below. This
information is required for epidemiologic follow-up. Item 4. Enter date of birth (not age). Items 5, 6, and 7. Indicate race, Hispanic ethnicity, and sex by checking appropriate box. These data are for statistical purposes only. Item 8. Enter county of residence of patient (Health Departments use county code). Item 9. Indicate if patient is a Medicaid client; if yes, enter Medicaid number. Enter Diagnosis Code or ICD-9 number. Enter submitter federal tax number or social security number in blank. ALSO ENTER RETURN ADDRESS OF SUBMITTER in box under “Send Report To.”
Right Upper Portion of Form. Specimen Type: Check appropriate box. Date Specimen Collected: Enter date as indicated. Examine For: Suspected disease or type examination required. Specimen Source: Check appropriate box. Symptoms/Epidemiological Information: Check appropriate box(es).
Provide any further information listed at top of this page.
Do not write in space below “Laboratory Report.”
DISPOSITION: This form may be destroyed in accordance with Standard 5, Patient Clinical Records, of the Records Disposition Schedule published by the N.C. Division of Archives and History.

Source: http://slph.ncpublichealth.com/Forms/DHHS-4121-SpecAtypBact-v2-withWorksheet.pdf