0920-1011 Respiratory Testing Form

Form Approved
OMB No. 0920-1011
Exp. Date 08/02/2020

Illinois Department of Public Health
Request for COVID-19 / Respiratory Testing

Public reporting burden of this collection of information is estimated to average 5 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 Reports Clearance Officer;
1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)

ILLINOIS DEPARTMENT OF PUBLIC HEALTH

Print using upper case letters.
Do not fax this form to the lab.

Request For COVID-19 / Respiratory Testing
SUBMITTER INFORMATION
AUTHORIZATION
CODE
NFORMATION:
SUBMITTER PHONE NUMBER

Fax Number for Reporting Result* (see instructions)

-

-

-

FAX REQUESTED

-

Yes

No

SUBMITTER'S NAME

STREET ADDRESS (Include apartment/suite number)

CITY

STATE

ZIP CODE

CONTACT PERSON

PHYSICIAN NAME

PATIENT INFORMATION
PATIENT'S FIRST NAME

AGE

BIRTHDATE

/

/

MEDICAID IDENTIFICATION NUMBER

PATIENT'S LAST NAME

PREGNANT
Yes

PATIENT'S IDENTIFICATION NUMBER

STREET ADDRESS (Include apartment/suite number)

No
SEX

ETHNICITY

RACE
White
African American/Black
Native American

Asian/Pacific Islander
Other
Unknown

CITY

STATE

Male
Female

Hispanic
Non-Hispanic

ZIP CODE

CELL NUMBER

-

-

TEST INFORMATION
DATE COLLECTED

TIME COLLECTED

/

APPROVED TESTING CRITERIA

SYMPTOM ONSET DATE

:

/

/

/

ONLY ONE (1) SAMPLE PER FORM
SPECIMEN SOURCE TYPE

TESTS REQUESTED
COVID-19

Arbovirus Panel

Nasopharyngeal Swab

Nasal Aspirate

Nasopharyngeal wash/aspirate

Respiratory Panel

Influenza

Pharyngeal Swab

Nasal Swab

Broncheoalveolar Lavage "BAL"

Oropharyngeal Swab

Sputum

Lower Respiratory Tract Aspirates

UNK

Other

LAB USE ONLY

Specimen Number Area Below
Reset
55836