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Laboratory use only:
________________________ _______________
Laboratory Number Date & Time
Alameda County Public Health Laboratory
2901 Peralta Oaks Ct., 2nd Floor
Oakland, CA 94605
Vici Varghese, Ph.D. HCLD (ABB), Director
(510) 382-4300 / FAX (510) 382-4333
CLIA NO: 05D2090025
Influenza Virus Test Panel
SPECIMEN SUBMISSION FORM
SUBMISSION CRITERIA FOR SPECIMEN TESTING:
☐Influenza-like Illness (ILI) defined as fever >37° (100°F) plus cough or sore throat
AND
At least one of the following:
☐Infants or children <18 years of age
☐Hospitalized patients (>24 hours) with suspected influenza
☐Patients who died of an acute illness in which influenza was suspected
☐Patients living in settings like long-term care facilities or other congregate living sites
Specimens that do not meet the above criteria will not be tested.
Patient’s Name: ___________________________ Gender: ____ DOB: ________ Race/Ethnicity_______________
Street Address: ___________________________________________________________________________________
City / State / Zip Code: ____________________________________________________________________________
Patient’s Medical Record Number: ___________________________________________
Location of Patient: ☐Hospital ICU ☐ Hospital (Non- ICU) ☐Long-term care facility ☐ Other ___________
Onset date of symptoms___________________________ Specimen Collection Date: _____________________
Submitting Hospital / Facility: _______________________________ Requesting Clinician: __________________
Phone Number: ( ) ___________________________________ Fax Number: ( ) ____________________
SPECIMEN SOURCE
☐Nasopharyngeal Swab (Preferred)
☐Nasal Swab
☐Throat Swab
☐Bronchial wash
☐Tracheal Aspirate
☐Other: __________________________
SPECIMEN REQUIREMENTS:
• Use Dacron swabs for collection
• Place specimens in viral
transport media (VTM)
• Store and transport at 4°C
(Refrigerate or wet ice)