Laboratory Results Form
Persistence of Ebola Virus in Body Fluids of Ebola Virus Disease Survivors in Sierra Leone
Attachment6_LaboratoryResultsForm
Laboratory Results Form
OMB: 0920-1149
A7
Page
Form Approved OMB
No. 0920-XXXX Exp.
Date xx/xx/xxxx
STUDY INFORMATION: RT-PCR |
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Question |
Pre-coded Responses |
Codes |
Skip to |
Code Boxes |
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Study participant ID |
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Name and code number of BMA/Lab Ass |
Name
_________________________ |
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Date of first analyses |
Date _________________________ |
Day |
Month |
Year |
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Laboratory name: |
Date _________________________ |
Day |
Month |
Year |
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Comments on specimens:
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(e.g. not enough material, accidents in handling, other disturbances, record specimen and date)
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(comment) (date)
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(comment) (date)
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(comment) (date)
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(comment) (date)
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Public reporting burden of
this collection of information is estimated to average 10
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/ATSDR Information Collection Review Office, 1600 Clifton Road
NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).
RT-PCR result |
(DATE) |
(DATE) |
(DATE) |
(DATE) |
(DATE) |
(DATE) |
(DATE) |
(DATE) |
(DATE) |
(DATE) |
(DATE) |
(DATE) |
Check if study ID matches all containers and vials |
yes |
yes |
yes |
yes |
yes |
yes |
yes |
yes |
yes |
yes |
yes |
yes |
Semen |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Vaginal secretion |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Breast Milk |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Cervix secretion |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Urine |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Sweat |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Saliva |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Rectal swab |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Tears |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos Neg |
Pos specimen frozen for further transport |
yes no |
yes no |
yes no |
yes no |
yes no |
yes no |
yes no |
yes no |
yes no |
yes no |
yes no |
yes no |
STUDY INFORMATION: Virus Isolation |
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Question |
Pre-coded Responses |
Codes |
Skip to |
Code Boxes |
Study participant ID |
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Name and code number of BMA/Lab Ass |
Name
_________________________ |
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Date of analyses |
Date __________________________ |
Day |
Month |
Year |
Name of laboratory |
Date __________________________ |
Day |
Month |
Year |
Comments on specimens: |
(comment) (date) (e.g. not enough material, accidents in handling, other disturbances, record specimen and date) |
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(comment) (date) |
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(comment) (date)
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(comment) (date)
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(comment) (date)
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Virus isolation |
(DATE) |
(DATE) |
(DATE) |
(DATE) |
(DATE) |
(DATE) |
(DATE) |
(DATE) |
(DATE) |
(DATE) |
(DATE) |
(DATE) |
Check if study ID matches all containers and vials |
yes |
yes |
yes |
yes |
yes |
yes |
yes |
yes |
yes |
yes |
yes |
yes |
Semen |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Vaginal secretion |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Breast milk |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Cervix secretion |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Urine |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Sweat |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Saliva |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Tears |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Rectal swab |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
Pos neg |
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | CDC User |
| File Modified | 0000-00-00 |
| File Created | 2021-01-24 |
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