CDC 57.207 Follow-up Laboratory Testing

Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Follow-up Laboratory Testing

Page 1 of 1

*required for saving **required for completion

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

O t h e r L a b s

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 HVC 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, v6.6