Facility ID:________________
| Lab #______________________________
|
*HCW ID#:_____________________
|
HCW Name, Last: ___________________ First: ________________________ Middle:_____________
|
*Gender: F M Other *Date of Birth: ____/_____/________
|
** Exposure Event #:____________________
|
Lab Results Lab test and test date are required.
|
| | Serologic Test
| Date
| Result
| | Other Test
| Date
| Value
|
HIV
| HIV EIA
| __/__/____
| P N I R
| | ALT
| __/__/____
| _____IU/L
|
Confirmatory
| __/__/____
| P N I R
| Amylase
| __/__/____
| _____IU/L
|
HCV
| anti-HCV-EIA
| __/__/____
| P N I R
| Blood glucose
| __/__/____
| ____mmol/L
|
anti-HCV-supp
| __/__/____
| P N I R
| Hematocrit
| __/__/____
| _____%
|
PCR HCV RNA
| __/__/____
| P N R
| Hemoglobin
| __/__/____
| _____gm/L
|
HBV
| HBs Ag
| __/__/____
| P N R
| Platelet
| __/__/____
| _____x109/L
|
IgM anti-HBc
| __/__/____
| P N R
| #Blood cells in urine
| __/__/____
| _____#/mm3
|
Total anti-HBc
| __/__/____
| P N R
| WBC
| __/__/____
| _____ x109/L
|
Anti-HBs
| __/__/____
| ____ mIU/mL
| Creatinine
| __/__/____
| _____μmol/L
|
| | Other: _____
| __/__/____
| _____ ____
|
Result Codes: P=Positive N=Negative I=Indeterminate R=Refused
|
Custom Fields
|
Label ___________________ ___/___/___ ___________________ ___________ ___________________ ___________ ___________________ ___________ ___________________ ___________ ___________________ ___________ ___________________ ___________
| Label ___________________ ___/___/____ ___________________ ___________ ___________________ ___________ ___________________ ___________ ___________________ ___________ ___________________ ___________ ___________________ ___________
|
Comments
|
| |
Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).
Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666).
CDC 57.207, v6.4
|
