NABL Accredited. ICMR Recognised Lab for COVID-19 Testing. ICMR Lab Code: GDCLD

NABL Accredited. ICMR Recognised Lab for COVID-19 Testing. ICMR Lab Code: GDCLD
ICMR Specimen Referral Form for COVID-19 (SARS-CoV2)
Introduction
This form is for collection centres / labs to enter details of the samples being tested for Covi-19. It is mandatory to fill this form for each and every sample being tested. It is essential that the collection centres/ labs exercise caution to ensure that correct information is captured in the form.
INSTRUCTION:
- Inform the local / district / state health authorities , especially surveillance officer for further guidance .
- Seek guidance on requirements for the clinical specimen collection and transport from Nodal officer.
- This form may be filled in and shared with the IDSP and Forwarded to a Lab where testing is planned
- Fields Marked With asterisk ( * ) are mandatory to be filled.
Choose One*
Normal PatientVIP Patient ( Reference Person Name )
Barcode*
Barcode Image*
SECTION A – PATIENT DETAILS
A.1 TEST INITIATION DETAILS
Sample Collected First Time*
YesNo
If No, Patient ID
A.2 PERSONAL DETAILS
Patient Name*
Father's Name
Age*
( If age less then 1 yr, please tick months checkbox )
Gender*
Occupation*
Health Care WorkerPoliceSanitationSecurity GuardsOther
Mobile Number*
Mobile No. Belongs to*
SelfFamily
Nationality*
IndianOther
Present patient address*
District*
State*
Pin code*
Downloaded Arogya Setu App*
YesNo
(These fields to be filled for all patients including foreigners)
Email*
example@example.com
Passport No. (For Foreign Nationals):
Aadhar No. ( For Indians ):
Received COVID-19 vaccine*
YesNo
If yes type of vaccine
CovaxinCovishield
Date of Dose 1
MonthDayYear
Date
Date of Dose 2
MonthDayYear
Date
*A.3 SPECIMEN INFORMATION FROM REFERRING AGENCY
Specimen Type*
Type of Test*
Name of kit used*
Collection Date*
MonthDayYear
Date
Sample ID Label:*
SymptomaticAsymptomatic
Contact of a lab confirmed case
YesNo
If, RT-PCR test, name of lab where sample is sent for testing
Mode of Transport used to visit testing facility*
BusMetroTrainCabAutoAmbulanceCarScootyBikeBicycleWalkNot Applicable
Please Note:- Hospital form is required for the patients visiting OPD, IPD and Emergency and Community form is required for patients under containment zone / Non-containment Area / Point of Entry / Testing on Demand.
A.3.1 For Community
Sample Collected From*
Containment ZoneNon-Containment AreaTesting on DemandPoint of Entry
Cat 1: All symptomatic (ILI symptoms) cases.
Containment Zone Non-containment area Testing on demand Point of entry.
Cat 2: All asymptomatic high-risk individuals (Any individual who falls under Section B2).
Cat 3: All symptomatic (ILI symptoms) individuals with history of international travel in the last 14 days Cat 4: All individuals who wish to get themselves tested.
A.3.2 For Hospital
*Fields marked with asterisk are mandatory to be filled.
Please Note: Section B1 and B2 need to be filled for both Community and Hospital settings. Section B3 needs to be filled only for Hospital Settings.
SECTION B- MEDICAL INFORMATION
B.1 CLINICAL SYMPTOMS AND SIGNS*
CoughSore ThroatFeverLoss of SmellLoss of TasteDiarrhoeaBreathlessnessNone of theseOther Symptoms, Please Specify
Date of onset of First Symptom
DayMonthYear
Date
B.2 PRE-EXISTING MEDICAL CONDITIONS*
DiabetesHeart DiseaseChronic Lung DiseaseChronic Kidney DiseaseOver weight / ObesityHypertensionCancerNone of theseOther Symptoms, Please Specify
B.3 HOSPITALIZATION DETAILS
Hospitalized
YesNo
Hospitalization Date
DayMonthYear
Date
Hospital Name
Hospital Complete Address
Hospital State
Hospital District
TEST RESULT (To be filled by Covid-19 testing lab facility)
Date of Sample Receipt
DayMonthYear
Date
Sample AcceptedRejected
Date of Testing
DayMonthYear
Date
Test Result
NegativePositive
Repeat Sample*
YesNo
Sign of Authority (Lab in charge)
Clear
Upload Aadhar Card*
Upload Passport ( For foreigner )
Take Photo
Should be Empty:

NABL Accredited. ICMR Recognised Lab for COVID-19 Testing. ICMR Lab Code: GDCLD

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

SECTION A – PATIENT DETAILS

A.2 PERSONAL DETAILS

*A.3 SPECIMEN INFORMATION FROM REFERRING AGENCY

A.3.1 For Community

A.3.2 For Hospital

SECTION B- MEDICAL INFORMATION

B.3 HOSPITALIZATION DETAILS

TEST RESULT (To be filled by Covid-19 testing lab facility)