SRFI

D( :0606400273705
RTPCR)

I
CMRSpec
imenRef
err
alFor
mfor
COVI
D-19(
SARS-
CoV2)

I
NTRODUCTI
ON:
This
formisf
orcol
lect
ionc ent
res/
labst
oenter
detai
l
s oft
hesamplesbei
ngtest
edforCovi
d-
19.I
ti
smandatory
tof
il
lthisf
ormforeach
andever
ysamplebei
ngt est
ed.I
ti
sessenti
alt
hatt
hecoll
ecti
oncent
res/l
absexer
cisecaut
iont
oens
uret
hat
cor
rect
inf
ormat
ioni
s
captur
edi
nthefor
m.
I
NSTRUCTI
ONS:
I
nformthelocal/di
str
ict
/st
ate healt
hauthori
ties,
especi
all
ysurv
eil
lanc
e offi
cerf
orfur
ther
gui
dance
Seekguidance onr
equir
eme ntsforthecl
ini
calspeci
menc oll
ect
ionandtranspor
tfr
omnodal
off
icer
Thi
sformmay befi
ll
edi
nands haredwiththeI
DSPandforwardedt
oalabwhe ret
esti
ngispl
anne
dFieldsmark edwit
haster
isk (
*)arema ndator
ytobefi
l
led
SECTI
ONA–PATI
ENTDETAI
LS

A.
1TESTI
NITI
ATI
ONDETAI
LS
*
Samplecol
l
e ct
edf
ir
stt
ime:
Yes No
I
fNo,
Pat
ient
ID:
A.
2PERSONALDETAI
LS
*
Pati
entName:JATIN Fat
her
'
sName:
*
Age:19Year s
*
Gender:
Male Female Other
s
*
Occupati
on:Other
*
Mobil
eNumber :8814831572 *
Mobi
l
eNumber
bel
ongst
o:Sel
f Fami
l
y
*
Nati
onali
tyI
:ndia
*
Present
pati
entaddressMPMAJRA
: *DownloadedAar
ogy
aSet
uApp:
Yes No
JHAJJAR Pincode:
*Di
str
ict
:JHAJJAR *Stat
e:HARYANA
(
The
sef
ie
ldst
obe
fil
l
edf
ora
llpa
ti
ent
sin
clu
din
gfor
ei
gne
rs)
AadhaarNo.(
ForIndi
ans)
:
*Passport
No.(f
orForei
gnNat
ional
s):
*
A.3SPECI
MENI
NFORMATI
ONFROM REFERRI
NGAGENCY

*Specimentype Thr
oat
Swab Nasal
Swab Endot
rachea Nasophar
yngeal
Swab
Bronchoal
veolar l
avag lAspi
rate

*Typeof est RT-

t PCR Rapi dAnt i
genTest(RAT)
*Coll
ect i
ondat e 15/01/ 2021
*Sampl eID(Label ) 50804
I
f,RT-
PCRt est ,
nameof l
abwher esampleissentf
ortest
ingMDRCG0 01-ModernDiagnost
ic&Resear
chCentreLaborator
y,Gur
ugr
am
*Modeof Trans por t
us edtovi
s i
ttesti
ngfacil
it
yPr i
vate-Sc ooty
Sy mptomat i
c Asy mptomat ic
Contac tofalabc onfirme dcase:Ye s No
PleaseNot e -
Hos pitalf
ormi sre quir
edf ort
h epati
entsvi
siti
ngOPD, I
PDandEme r
gencyandCommunityfor
misrequi
redf
orpat
ients
unde r
c ontainme ntzone/Non- contai
nme ntarea/Point
ofentr
y/Testi
ngondemand
*
A.3.
1ForCommuni
ty
Sampl
ecol
l
ect
edf
rom
Cat6:Al
lsy
mpt
omat
ic(
ILIsy
mpt
oms)pat
ient
spr
esent
ingi
naheal
thcar
eset
ti
ng

NI
C- Page1of
2 1/
17/
20215:
56:
16P
(
htt
ps:
//cov
id19cc.
nic.
in) M
 *
A.3.
2ForHospi
tal

NotAppl
icabl
e

*Fiel
dsmar kedwi t
hasteriskaremandat oryt
obefil
led
Pl
easeNot
e:Sect
ionB1andB2needt
obef
il
ledf
orbot
hCommuni
tyandHospi
tal
set
ti
ngs.
Secti
onB3needst obefi
l
ledonlyf
orHospit
alset
ti
ngs
Sect
ionB-MEDI
CALI
NFORMATI
ON

B.
1CLI
NICALSYMPTOMSANDSI
GNS
Cough Loss of
tast
e
Soret
hroat Di
arr
hoea
Fev
er Br
eathl
essness
Lossofsmel
l Ot
hersymptoms ,
pl
easespeci
fy
Dateof
onsetof
Fir
stSy
mpt
om:
B.
2PRE-
EXI
STI
NGMEDI
CALCONDI
TIONS
Di
abet es Ov erwei
ght/Obesit
y
Heartdisease Hypert
ension
Chroniclungdi
sease Cancer
ChronicKidneydi
sease Any other
pleasespeci
fy
B.
3HOSPI
TALI
ZATI
ONDETAI
LS
NotAppl
icabl
e

TESTRESULT(
Tobef
il
ledbyCov
id-
19t
est
ingl
abf
aci
li
ty)
Si
gnofthe
Dat
eof
sampl
ereceiSample Dat
eof
test
in Testresul
t RepeatSample Aut
hor
ity
(Labi
pt(
dd/
mm/yy
) accept
ed/
Rej
ect g (Posi
tiv
e/Negat
i requi
red(
Yes
/N
nchar
ge)
ed (
dd/mm/y
y) ve) o)

16/
01/
202 accept
ed 16/
01/
2021

NI
C- Page2of
2 1/
17/
20215:
56:
16P
(
htt
ps:
//cov
id19cc.
nic.
in) M