Covid -19 Booth Copy


ICMR Specimen Referral Form for COVID-19 (SARS-CoV2)


• Fields marked with asterisk (*) are mandatory to be filled

SECTION A – PATIENT DETAILS
A.1 TEST INITIATION DETAILS

  • *Repeat Sample:
  • If Yes, Patient ID:

A.2 PERSONAL DETAILS

  • *Patient Name:
  • *Patient in quarantine facility:
  • Gender:
  • *Present Village or Town:
  • *Mobile Number:
  • *District of Present Residence:
  • Mobile Number belongs to :
  • *Present patient address:
  • Nationality:
  • *Pincode:
  • Download Aarogya Setu app:
    (These fields to be filled for all patients including foreigners)

  • *Email:
  • Passport No. (For Foreign Nationals):
  • * Aadhar No.(For indians) :
  • Father Name/ Husband Name (As
    mentioned in aadhar Card

A.3 SPECIMEN INFORMATION FROM REFERRING AGENCY

Specimen type :
  • Collection Date :
  • Sample Collection By :
  • Sample ID (Label):
  • Sample Collector’s Phone No. :

*A.4 PATIENT CATEGORY (PLEASE SELECT ONLY ONE)

A.4.1 Routine surveillance in containment zones and screening at points of entry

  • Cat 1: All symptomatic (ILI symptoms) cases including health care workers and frontline workers:
  • Cat 2: All asymptomatic direct and high-risk contacts (contacts in family and workplace, elderly ≥ 65 years of age, those with comorbidities etc.:
  • Cat 3: All asymptomatic high-risk individuals:

A.4.2 Routine surveillance in non-containment areas

  • Cat 4: All symptomatic (ILI symptoms) individuals with history of international travel in the last 14 days:
  • Cat 5: All symptomatic (ILI symptoms) contacts of a laboratory confirmed case:
  • Cat 6: All symptomatic (ILI sym ptoms) health care workers / frontline workers involved in containment and mitigation activities:
  • Cat 7: All symptomatic ILI cases among returnees and migrants within 7 days of illness:
  • Cat 8: All asymptomatic high-risk contacts (contacts in family and workplace, elderly ≥ 65 years of age, those with co-morbidities etc.:

A.4.3 In Hospital Settings

  • Cat 9: All patients of Severe Acute Respiratory Infection (SARI):
  • Cat 10: All symptomatic (ILI symptoms) patients presenting in a healthcare setting:
  • Cat 11: Asymptomatic high-risk patients who are hospitalized or seeking immediate hospitalization:
  • Cat 12: Asymptomatic patients undergoing surgical / non-surgical invasive procedures (not to be tested more than once a week during hospital stay):
  • Cat 13 : All pregnant women in/near labour who are hospitalized for delivery:
  • Cat 14: All symptomatic neonates presenting with acute respiratory / sepsis like illness:
  • Cat 15 :Patients presenting with atypical manifestations [stroke, encephalitis, hemoptysis, pulmonary embolism, acute coronary symptoms, Guillain Barre syndrome, Multiple Organ Dysfunction Syndrome,progressive gastrointestinal symptoms, Kawasaki Disease (in pediatric age group)]based on the discretion of the treating physician:

A.4.4 Testing on demand

  • Cat 16: All individuals undertaking travel to countries/Indian states mandating a negative COVID-19 test at point of entry:
  • Cat 17: All individuals who wish to get themselves tested:
  • Other: (please specify) * (Select “other" only if the patient doesn’t belong to category 1-17):

SECTION B- MEDICAL INFORMATION

B.1 CLINICAL SYMPTOMS AND SIGNS

  • Symptoms Yes
    Cough
    Breathlessness
    Sore throat
  • Symptoms Yes
    Diarrhoea
    Nausea
    Chest pain
  • Symptoms Yes
    Vomiting
    Haemoptysis
    Nasal discharge
  • Symptoms Yes
    Fever at evaluation
    Body ache
    Sputum
  • Symptoms Yes
    Abdominal pain

B.2 PRE-EXISTING MEDICAL CONDITIONS

  • Condition Yes
    Chronic lung disease
    Chronic renal disease
  • Condition Yes
    Malignancy
    Diabetes
  • Condition Yes
    Heart disease
    Hypertension
  • Condition Yes
    Chronic liver disease
  • Immunocompromised condition:
  • Other underlying conditions:

B.3 HOSPITALIZATION DETAILS

  • Hospitalized:
  • Hospital State :
  • Hospital ID/ Number:
  • Hospital District:
  • Hospitalization Date:
  • Hospital Name:

B.4 REFERRING DOCTOR DETAILS

  • Name of Doctor :
  • Doctor Mobile No.:
  • Doctor Email ID :
  • Doctor Prescription
  • *Aadhaar Card (Front Side)
  • *Aadhaar Card (Back Side)
  • Passport (Front Side)
  • Passport (Back Side)
COVID-19 Collection Centre
1