• 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.
  • Barcode Image*

  • SECTION A – PATIENT DETAILS

    A.1 TEST INITIATION DETAILS
  • Sample Collected First Time*

  • A.2 PERSONAL DETAILS

  • ( If age less then 1 yr, please tick months checkbox )
  • Occupation*
  • Mobile No. Belongs to*
  • Downloaded Arogya Setu App*

  • (These fields to be filled for all patients including foreigners)

  • Received COVID-19 vaccine*
  • If yes type of vaccine
  • Date of Dose 1
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Dose 2
     - -
    2 digit month, 2 digit day, 4 digit year

  • *A.3 SPECIMEN INFORMATION FROM REFERRING AGENCY

  • Collection Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Contact of a lab confirmed case
  • Mode of Transport used to visit testing facility*

  • 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*

  • 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*
  • Date of onset of First Symptom
     - -
    2 digit day, 2 digit month, 4 digit year
  • B.2 PRE-EXISTING MEDICAL CONDITIONS*

  • B.3 HOSPITALIZATION DETAILS

  • Hospitalized
  • Hospitalization Date
     - -
    2 digit day, 2 digit month, 4 digit year

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

  • Date of Sample Receipt
     - -
    2 digit day, 2 digit month, 4 digit year
  • Date of Testing
     - -
    2 digit day, 2 digit month, 4 digit year
  • Test Result
  • Repeat Sample*
  • Clear
  • Upload Aadhar Card*
  • Upload Passport ( For foreigner )
  • Take Photo
  • Should be Empty:
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