Form Dhhs T806 – Fill Out and Use This PDF

SPECIAL/ATYPICAL BACTERIOLOGY

LABORATORY REPORT (DO NOT WRITE BELOW)

Comments:

DHHS T806 (Revised 10/08) LABORATORY (Review 10/10)

PLEASE PROVIDE THE FOLLOWING CLINICAL OR EPIDEMIOLOGIC INFORMATION

EPIDEMIOLOGICAL DATA:  SINGLE CASE SPORADIC CONTACT EPIDEMIC CARRIER ANIMAL CONTACT ___________

FOREIGN OR DOMESTIC TRAVEL? WHERE? _____________________________ WHEN? (WITHIN LAST YEAR ) _____________________________

OTHER _______________________________________________________________________________________________________________________

INSTRUCTIONS

PURPOSE:  Isolation, identiication, conirmation, further studies of human disease-producing mycobacteria.

PREPARATION:  Collect specimen following instructions in SCOPE, using recommended collection kits. Label each specimen tube, subculture, or smear with patient's name and your laboratory number if appropriate. Fill out this form and send in appropriate mailer with the specimen to State Labo- ratory 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 Web site.

PREPARATION OF FORM: Left Upper Portion of Form. Item 1. Enter patient's name, last name irst, irst name, and middle initial or maiden name initial, if female. Item 2. Enter patient's social security number. This is the identifying number for that patient. If the patient has no social security number, please indicate on form and include submitter laboratory/medical record 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 Ethnic- ity, 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. Item 10. Indicate if patient is a Family Planning or EPSDT client by checking box. 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.

DHHS T806 (Revised 10/08) LABORATORY (Review 10/10)