CDC SPECIMEN SUBMISSION FORM


Justification must be completed by State Health Department Laboratory before specimen can be accepted by CDC.
Please check the first applicable statement and when appropriate complete the statement with the *.

1. Disease suspected to be of public health importance. Specimen is:
(a)___ from an outbreak
(b)___ from uncommon or exotic disease
(c)___ an isolate that cannot be identified, is atypical, shows multiple antibiotic resistance or 
	from a normally sterile site(s)
(d)___ from a disease for which reliable diagnostic reagents or expertise are unavailable in State.

2. ___ Ongoing collaborative CDC/State project

3. ___ Confirmation of results requested for quality assurance.

*Prior arrangement for testing has been made.
Please bring to the attention of:

(Name):____________________________________________

Completed by:______________________________________

Date:______________________________________________

Name, Address and Phone Number of Physician or Organization:





State Health Department Laboratory Address:





Telephone Number:__________________________________

Fax Number:________________________________________

State Health Department Number:____________________

Date Sent to CDC:__________________________________

Patient Identification (Hospital No.):_____________

Name:______________________________________________
	Last,            First,                Mi

Birthdate:_________________________________________
	      (MM/DD/YYYY)

Sex:  ____ Male    ____ Female

Clinical Diagnosis:________________________________

Associated Illness:________________________________

Date of Onset:_____________________________________
		   (MM/DD/YYYY)

Fatal?  ___ Yes    ___ No

(FOR CDC USE ONLY)

UNIT	FY		NUMBER		SUF

_____	_____	_____________________	___________

DATE RECEIVED:_____________________________________
		MO           DA          YR


REVERSE SIDE OF THIS FORM MUST BE COMPLETED


THIS FORM MUST BE EITHER PRINTED OR TYPED
PLEASE PREPARE A SEPARATE FORM FOR EACH SPECIMEN

D.A.S.H.

DATE REPORTED


_____	_____	_____
 MO	 DA	 YR


Department of Health and Human Services
Public Health Service
Centers for Disease Control
Center for Infectious Diseases
Atlanta, Georgia  30333


The Centers for Disease Control (CDC), an agency of the Department of Health 
and Human Services, is authorized to collect this information, including the 
Social Security number (if applicable), under provisions of the Public Health 
Service Act, Section 301 (42 U.S.C. 241). Supplying the information is voluntary 
and there is no penalty for not providing it. The data will be used to increase 
understanding of disease patterns, develop prevention and control programs, and 
communicate new knowledge to the health community. Data will become part of CDC 
Privacy Act system 09-20-0106, "Specimen Handling for Testing and Related Data" 
and may be disclosed: to appropriate State or local public health departments 
and cooperating medical authorities to deal with conditions of public health 
significance; to private contractors assisting CDC in analyzing and refining 
records; to researchers under certain limited circumstances to conduct further 
investigations; to organizations to carry out audits and reviews on behalf of 
HHS; to the Department of Justice in the event of litigation, and to a 
congressional office assisting individuals in obtaining their records. 
An accounting of the disclosures that have been made by CDC will be made 
available to the subject individual upon request. Except for permissible 
disclosures expressly authorized by the Privacy Act, no other disclosure 
may be made without the subject individual's written consent.

CDC 50.34 Rev 09/2002 (FRONT)  -CDC SPECIMEN SUBMISSION FORM-


LABORATORY EXAMINATIONS REQUESTED:
___ ANtimicrobial Susceptability
___ HIstology
___ IDentification
___ ISolation
___ SErology (Specific Test)_______________________
___ OTher:(Specify)________________________________


CATEGORY OF AGENT SUSPECTED:
___ BActerial
___ VIral
___ FUngal
___ RIckettsial
___ PArasitic
___ OTher (Specify)________________________________

SPECIFIC AGENT SUSPECTED:


OTHER ORGANISM FOUND:

ISOLATION ATTEMPTED?  ___ YES    ___ NO

NO. OF TIMES ISOLATED:

NO. OF TIMES PASSED:

SPECIMEN SUBMITTED IS:
___ Original Material
___ Pure Isolate
___ Mixed Isolate

DATE SPECIMEN TAKEN:_______________________________
		     	  MO     DA      YR

ORIGIN:
___ HUman
___ FOod
___ SOil
___ ANimal
___ OTher (Specify):_______________________________
___ (Specify):_____________________________________

SOURCE OF SPECIMEN:
___ BLood
___ GAstric
___ SErum
___ SPutum
___ URine
___ CSf
___ HAir
___ SKin
___ STool
___ THroat
___ WOund (Site)___________________________________
___ EXudate (Site)_________________________________
___ Tissue (Specify)_______________________________
___ OTher (Specify)________________________________

SUBMITTED ON:
___ MEdium_________________________________________
___ ANimal_________________________________________
___ TIssue Culture (Type)__________________________
___ EGg
___ OTher (Specify)________________________________

SERUM INFORMATION: 		MO     DA       YR
___ ACute _________________________________________
___ COnvalescent___________________________________
___ S3_____________________________________________
___ S4_____________________________________________
___ S5_____________________________________________

IMMUNIZATIONS:				 MO    YR
(1.)_______________________________________________

(2.)_______________________________________________

(3.)_______________________________________________

(4.)_______________________________________________

TREATMENT: 			Date	  Date
				Begun	  Completed
DRUGS USED     ___ NONE		MO DA YR  MO DA YR

(1.)________________________	________  _________

(2.)________________________	________  _________

(3.)________________________	________  _________

EPIDEMIOLOGICAL DATA:
___ SHingle Case
___ SPoradic
___ COntact
___ EPidemic
___ CArrier

Family illness_______________________________________

Community Illness____________________________________

Travel and Residence (Location)
___ FOreign__________________________________________

___ USA______________________________________________

Animal Contacts (Species)____________________________

Anthropod Contacts: 
___ None  ___ Exposure Only  ___ Bite

Type of Arthropod:___________________________________

Suspected Source of Infection:_______________________

SIGNS AND SYMPTOMS:
___ FEver  
Maximum Temperature_____________
Duration:__________________ Days

___ CHills

SKIN:
___ MAculopapular
___ HEmorrhagic
___ VEsicular
___ Erythema Nodosum
___ Erythema Marginatum
___ OTher:____________________________________________

RESPIRATORY:
___ RHinitis
___ PUlmonary
___ PHaryngitis
___ CAlcifications
___ Otitis Media
___ PNuemonia (type)__________________________________
___ OTher:____________________________________________

CARDIOVASCULAR:
___ MYocarditis
___ Pedicarditis
___ ENdocarditis
___ OTher:____________________________________________

GASTROINTESTINAL:
___ DIarrhea
    ___ BLood
    ___ MUcous
___ COnstipation
___ ABnormal Pain
___ VOmiting
___ OTher:_____________________________________________

CENTRAL NERVOUS SYSTEM
___ HEadache
___ MEningismus
___ MIcrocephalus
___ HYdrocephalus
___ SEizures
___ CErebral Calcification
___ CHorea
___ PAralysis
___ OTher:______________________________________________

MISCELLANEOUS:
___ JAundice
___ MYalgia
___ PLeurodynia
___ COnjunctivitis
___ CHorioretinitis
___ SPlenomegaly
___ HEpatomegaly
___ LIver Abscess/cyst
___ LYmphadenopathy
___ MUcous Membrane Lesions
___ OTher:_______________________________________________

STATE OF ILLNESS:
___ SYmptomatic
___ ASymptomatic
___ SUbacute
___ CHronic
___ DIsseminated
___ LOcalized
___ EXtraintestinal
___ OTher:________________________________________________


PREVIOUS LABORATORY RESULTS/OTHER CLINICAL INFORMATION:
(Information supplied should be related to this case and/or 
specimen(s) and relative to the test(s) requested.

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

	
		UNIT	FY	NUMBER		SUF.

CDC NUMBER	_____	____	___________	___________


CDC 50.34 Rev 09/2002 (BACK) -CDC SPECIMEN SUBMISSION FORM-