Form 57.155 Point of Care Testing Results

F orm Approved

OMB No. 0920-1317

Exp. Date: 3/31/2026

www.cdc.gov/nhsn

Point of Care Testing Results

NOTE: Submission of data elements on this form is agreement for CDC to convert and electronically transmit the data to the State and local health departments as a part of communicable disease surveillance and control and to assist in meeting reporting requirements.

Page 1 of 1	*Required for saving ^conditionally required
Facility ID:				*Type of Individual Tested:
^Resident ID:			^Staff ID:					^Visitor ID:
*First Name:		Middle Name:			*Last Name:
*Gender: F M Other			*Date of Birth:
Sex at Birth: F M Unknown			Gender Identity (Specify): Male Female Male-to-female transgender Female-to-male transgender Identifies as non-conforming Other Asked but unknown
*Ethnicity (Specify): Hispanic or Latino Not Hispanic or Latino Unknown Declined to respond			*Race (Select all that apply: American Indian or Alaska Native Asian Black or African American Middle Eastern or North African Native Hawaiian or Pacific Islander White Unknown Declined to respond
Preferred Language: (Specify)			Interpreter Needed: (Specify)
*Address, line 1			^Address, line 2
*City:			*State:
*Zip Code:			*County:
*Contact Phone:			Ext:
POC Test Results
*Test Date:
*Device Name:
*Specimen Source:
*Test Result:
*Specimen Number:
*Ordering Physician:
*Was person symptomatic?
*Was person pregnant?
Ordering Physician
Address, line 1						Address, line 2
City:						State:
*Zip Code:
Work Phone:						Ext:

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 12 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 H21-8, Atlanta, GA 30333, ATTN:  PRA (0920-0666).