CDC 50.34_v4.2.21 CDC SPECIMEN SUBMISSION FORM: SPECIMENS OF HUMAN ORGAN

Select the Specimen Origin to Begin the Form

Form Approved | OMB Control No.: 0920-1309 | Expiration Date: 11/30/2023

CDC SPECIMEN SUBMISSION FORM: SPECIMENS OF HUMAN ORIGIN

HUMAN

LABORATORY EXAMINATION REQUESTED

STATE PHL / NEW YORK CITY DEPARTMENT OF HEALTH & MENTAL HYGIENE / FEDERAL AGENCY /
INTERNATIONAL INSTITUTION / PEACE CORPS

Test order name:

Name: (Laboratory Director or designee)

Test order code:
Suspected Agent:

Prefix

Last

First

MI

Suffix

Degree

Institution name:

Date sent to CDC:
At CDC, bring to the attention of:

Street Address:
Line 1

PATIENT INFORMATION

Line 2

Patient Name:

City

Last

First

MI

Birth date:

Suffix

State

Case ID:

Race:

Age:
White

Age Units:

Black or African American

Native Hawaiian and Other Pacific Islander

Prefix

Local Number (e.g. 6390000)

Institutional e-mail

Last

First

MI

Suffix

Degree

Phone:

Clinical Diagnosis:

Fatal:

Area Code

Point of Contact: (Person to be contacted if there is a question regarding this order)
Asian

American Indian and Alaska Native

Date of onset:

Country

Fax:
Country Code

Sex:

ZIP Postal Code

Country Code

Pregnancy Status:
Date of Death:

SPECIMEN INFORMATION

Area Code

Local Number (e.g. 6390000)

Patient ID:

Alternative Patient ID:

Specimen ID:

Alternative Specimen ID:

POC e-mail

ORIGINAL SUBMITTER
(Organization that originally submitted specimen for testing)

Specimen collected date:

Time:

--:-- --

Name: (Laboratory Director or designee)

Material Submitted:
Prefix

Specimen source (type):

Last

First

MI

Suffix

Degree

Institution name:

Specimen source modifier:

Street Address:

Specimen source site:

Line 1

Specimen source site modifier:
Line 2

Collection method:
City

Treatment of specimen:
Transport medium/Specimen
preservative:

ZIP Postal Code

State

Country

Fax:
Country Code

Specimen handling:

Area Code

Local Number (e.g. 6390000)

Institutional e-mail

Point of Contact: (Person to be contacted if there is a question regarding this order)

CDC USE ONLY

Prefix

Package ID#: _________________________________________
Delivered to Unit #: _________________________________
Opened By: __________________________________________
Unit Specimen ID#: __________________________________

Barcode 1

Condition

Specimen Container

STAT Laboratory

Country Code

CDC Specimen

MI

Area Code

Local Number (e.g. 6390000)

Patient ID:

Alternative Patient ID:

Specimen ID:

Alternative Specimen ID:

Identification label

Suffix

Degree

POC e-mail

INTERMEDIATE SUBMITTER
(Complete if specimen is submitted to SPHL through an intermediate agency)

Date received at STAT: _________/__________/_________

Outer Package

First

Phone:

Date received at CDC: __________/__________/_________

Date received in testing lab: _______/________/_______

Last

Time: ______________________
Testing Laboratory

Name: (Laboratory Director or designee)
Prefix

Last

First

MI

Suffix

Degree

Institution name:
Street Address:
Line 1

Specimen

Line 2

City

ZIP Postal Code

State

Country

Fax:
Country Code

Area Code

Local Number (e.g. 6390000)

Institutional e-mail

Point of Contact: (Person to be contacted if there is a question regarding this order)
Prefix

Last

First

MI

Suffix

Degree

Phone:
Country Code

CDC 50.34 HUMAN (Page 1)

Area Code

Local Number (e.g. 6390000)

Patient ID:

Alternative Patient ID:

Specimen ID:

Alternative Specimen ID:

CDC SPECIMEN SUBMISSION FORM: SPECIMENS OF HUMAN ORIGIN

POC e-mail

Version 4.2.21-e - Expiration Date 12/8/2023

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 0920-1309.

CDC SPECIMEN SUBMISSION FORM: SPECIMENS OF HUMAN ORIGIN
Patient Name:
Last

AND/OR Original Patient ID:

AND/OR SPHL Specimen ID:

First

PATIENT HISTORY

BRIEF CLINICAL SUMMARY
(Include signs, symptoms, and underlying illnesses if known)

STATE OF ILLNESS

TYPE OF INFECTION

THERAPEUTIC AGENT(S) DURING ILLNESS

Agent

Symptomatic

Upper respiratory

Sepsis

Asymptomatic

Lower respiratory

Central nervous system

Acute

Cardiovascular

Skin/soft tissue

Chronic

Gastrointestinal

Ocular

Convalescent

Genital

Joint/bone

Recovered

Urinary tract

Disseminated

Start Date

End Date

1
2
3

Other, specify

EPIDEMIOLOGICAL DATA

EXTENT

TRAVEL HISTORY

Isolated Case
Carrier

Travel:

Dates of Travel:

Travel: Foreign (Countries)

Travel: United States (States)

Foreign Residence (Country)

United States Residence (State)

to

Contact
Outbreak
Family
Community
Healthcare-associated
Epidemic

EXPOSURE HISTORY

Note: Additional states or countries of residence or travel should be entered in the Brief Clinical Summary field.

RELEVANT IMMUNIZATION HISTORY

Exposure:

Immunization(s)

Date of Exposure:
Animal

Type of Exposure:

2

Common Name:

3

Scientific Name:
Arthropod

Date Received

1

Type of Exposure:

4

Common Name:
Scientific Name:

COMMENTS

Barcode 3

Barcode 2

CDC USE ONLY

PREVIOUS LABORATORY RESULTS
(Or attach copy of test results or worksheet)

The Centers for Disease Control and Prevention (CDC), an agency of the Department of Health and Human Services, is authorized to collect this information, including the Social Security number (if applicable), under provisions of the Public
Health Service Act, Section
301 (42 U.S.C. 241). Supplying the information is voluntary and there is no penalty for not providing it. The data will be used to increase understanding of disease patterns, develop prevention and control programs,
and communicate new knowledge to the health
community. Data will become part of CDC Privacy Act system 09-20-0106, "Specimen Handling for Testing and Related Data" and may be disclosed: to appropriate State or local public health
departments and cooperating medical authorities to deal with conditions of
public health significance; to private contractors assisting CDC in analyzing and refining records; to researchers under certain limited circumstances to conduct further
investigations; to organizations to carry out audits and reviews on behalf of HHS; to the Department
of Justice in the event of litigation, and to a congressional office assisting individuals in obtaining their records. An accounting of the disclosures
that have been made by CDC will be made available to the subject individual upon request. Except for permissible
disclosures expressly authorized by the Privacy Act, no other disclosure may be made without the subject individual's written
consent. Please refer to the CDC Infectious Diseases Laboratories Test Directory for information on specimen requirements. CDC must maintain
and document specific acceptance criteria to perform laboratory tests on samples obtained from humans
pursuant to the Clinical Laboratory Improvement Amendments of 1988 (CLIA) and accompanying regulations. 42 U.S.C. § 263a; 42 C.F.R. § 493.1241.
Samples
transferred to the CDC for testing or any other purpose will become the legal property of the agency unless otherwise agreed upon in writing. Samples will not be returned to the submitting entity.

CDC 50.34 HUMAN (Page 2)

CDC SPECIMEN SUBMISSION FORM: SPECIMENS OF HUMAN ORIGIN

Version 4.2.21-e - Expiration Date 12/8/2023