Positive Influenza Test Result Report Form
Please complete this form to report a positive influenza test result. All fields are required for accurate reporting. Do not enter sensitive personal or financial information.
Patient Initials
*
Patient Date of Birth (Year Only)
*
Date of Symptom Onset
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Test
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Influenza Test Performed
*
Please Select
Rapid Influenza Diagnostic Test (RIDT)
RT-PCR
Viral Culture
Immunofluorescence
Other
Test Location
*
Please Select
Hospital
Clinic
Laboratory
Home Test
Other
Reporting Facility Name
*
Reporter Full Name
*
First Name
Last Name
Reporter Email Address
*
example@example.com
Additional Notes (optional)
Submit Report
Should be Empty: