Patient Laboratory Record

Project ID number:_______________

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/20XX

Attachment 6. Patient Laboratory Record

Laboratory Testing Results

[Check one:]

___ Case-Patient MOH Number: __________________________

___ Contact-Case MOH Number: __________________________

Collection date (DD/MM/YYYY)	Location of Test	Test Performed	Test date (DD/MM/YYYY)	Results			Lab Case ID
_ _ / _ _ / _ _ _ _	 Lab 1 (0)  Lab 2 (1)  Lab 3 (2)  Lab 4 (3)  Lab 5 (4)  Other (9)	 Whole blood (0)  Swab (1)  Serum (2)  Post-mortem heart blood (3)  Other (9)	_ _ / _ _ / _ _ _ _	 Not Case (0)  Confirmed Acute (1)  Confirmed Convalescent (2)  Indeterminate (3)  Needs follow-up sample (4)	Cycle threshold-1 (Ct) [ENTER 99 IF MISSING]	Cycle threshold-2 (Ct) [ENTER 99 IF MISSING]
_ _ / _ _ / _ _ _ _	 Lab 1 (0)  Lab 2 (1)  Lab 3 (2)  Lab 4 (3)  Lab 5 (4)  Other (9)	 Whole blood (0)  Swab (1)  Serum (2)  Post-mortem heart blood (3)  Other (9)	_ _ / _ _ / _ _ _ _	 Not Case (0)  Confirmed Acute (1)  Confirmed Convalescent (2)  Indeterminate (3)  Needs follow-up sample (4)	Cycle threshold-1 (Ct) [ENTER 99 IF MISSING]	Cycle threshold-2 (Ct) [ENTER 99 IF MISSING]

Notes:

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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

Patient Laboratory Record, V1.0, 14 Dec 2014