Coronavirus disease (COVID-19) technical guidance by WHO Laboratory testing for COVID-19 | Seite 10

Laboratory testing for coronavirus disease 2019 (COVID-19) in suspected human cases
Annex I
COVID-19 virus LABORATORY TEST REQUEST FORM 1
Submitter information
NAME OF SUBMITTING HOSPITAL, LABORATORY, or OTHER
FACILITY*
Physician
Address
Phone number
Case definition 2 :
☐ Suspect case ☐ Probable case
Patient info
First name
Patient ID number
Address
Last name
Date of Birth
Sex
Age:
☐ Male ☐ Female ☐
Unknown
Phone number
Specimen information
☐ Nasopharyngeal and oropharyngeal swab ☐ Bronchoalveolar lavage ☐ Endotracheal aspirate
☐ Nasopharyngeal aspirate ☐ Nasal wash ☐ Sputum ☐ Lung tissue ☐ Serum ☐ Whole blood
☐ Urine ☐ Stool ☐ Other: ….
All specimens collected should be regarded as potentially infectious and you must contact the reference
Type
laboratory before sending samples.
All samples must be sent in accordance with category B transport requirements.
Please tick the box if your clinical sample is post mortem ☐
Date of collection
Time of collection
Priority status
Clinical details
Date of symptom onset:
Has the patient had a recent history of
Country
☐ Yes
travelling to an affected area?
Return date
☐ No
Has the patient had contact with a confirmed case?
Additional
Comments
☐ Yes ☐ No ☐ Unknown ☐ Other exposure:
© World Health Organization 2020. All rights reserved.
This is a draft. The content of this document is not final, and the text may be subject to revisions before
publication. The document may not be reviewed, abstracted, quoted, reproduced, transmitted, distributed,
translated or adapted, in part or in whole, in any form or by any means without the permission of the World
Health Organization.
WHO reference number: WHO/COVID-19/laboratory/2020.4
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Form in accordance with ISO 15189:2012 requirements
https://www.who.int/publications-detail/global-surveillance-for-human-infection-with-novel-coronavirus-(2019-ncov)
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