Fillable COVID-19 Testing Approval Form Fillable

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COVID-19 Testing Approval Form Fillable

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KDHE Coronavirus Disease 2019 (COVID-19) Testing
Kansas COVID-19 PUI Criteria, Testing Form, and Shipping Guidance (03/18/2020)
Facilities and providers should prioritize using internal or commercial laboratory testing for COVID-19. The
following reference labs offer COVID-19 testing; Quest Diagnostics (test code 39433), LabCorp (test code
139900), Mayo Clinic Laboratories (test code ZW282), and Viracor (test code 8398). Testing at the Kansas
Health and Environmental Laboratories will be prioritized for public health purposes and urgent need.
If you are unable to test at a reference laboratory, fill out the following criteria to ensure that your
patient meets the definition of a Person Under Investigation (PUI) and will be approved for testing.
Epidemiologic Risk
&
Clinical Features
Close contact^ with a person that
has laboratory-confirmed
COVID-19 and developed
symptoms within 14 days of
contact
and
Measured fever above 100°F
or
Lower
respiratory illness (cough or
shortness of breath).
If the Epidemiologic Risk criterion and Clinical
Features criterion are not met, COVID-19 testing
will not be conducted.
History of travel outside of Kansas
within 14 days of symptom onset
and
Measured fever above 100°F
and
Lower respiratory symptoms (cough or shortness of
breath)
and
Other respiratory tests were performed and are
negative
If the Epidemiologic Risk criterion and all three
Clinical Features criteria are not met, COVID-19
testing will not be conducted.
No source of exposure has been
identified
Kansas resident in a county
with sustained community
transmission*
and
Severe respiratory illness
and
Hospitalized
and
Other respiratory tests
were performed and are
negative
If the Epidemiologic Risk criterion and all three
Clinical Features criteria are not met, COVID-19
testing will not be conducted.
^Being wi
thin 6 feet for a prolonged period (10 minutes or longer) or having direct contact with infectious
secretions of a COVID-19 case (e.g., being coughed on)
*Currently this only includes Johnson County
KDHE Coronavirus Disease 2019 (COVID-19) Testing
Kansas COVID-19 PUI Criteria, Testing Form, and Shipping Guidance (03/18/2020)
PROVIDER INFORMATION
PATIENT INFORMATION
SPECIMEN COLLECTION AND SHIPPING INSTRUCTIONS
SYMPTOMS AND EXPOSURE INFORMATION
Facility Name: Clinician Name:
Facility Address: City: State:
24/7 Phone Number for Positive Results (e.g., Hospital Lab, Infection Prevention):
Lab report delivery preference:
☐
Fax #:
☐
Secure Email:
•
Patients not meeting Person Under Investigation (PUI) criteria will be rejected.
• Fax the completed form to 877-427-7318. Calling the hotline is no longer required.
• Include a copy of the form with the specimen shipment to KHEL.
Name (Last, First): DOB:
☐
Male
☐
Female
Address: City: State: ZIP:
Home Phone Number: Parent/Guardian Name:
Mobile Phone Number: Ethnicity: ☐ Non-Hispanic ☐ Hispanic ☐ Unknown
Race:
☐
White
☐
Black
☐
Asian
☐
Amer. Indian/Alaska Native
☐
Native Hawaiian/Pacific Islander
NASOPHARYNGEAL SWAB Collection Date:
An oropharyngeal swab is not required. Ensure specimen is closed tightly to avoid leaking while shipping.
Symptoms: ☐ Fever ☐ Cough ☐ Shortness of Breath ☐ Pneumonia ☐ Acute Respiratory Distress
Hospitalized? ☐ Yes ☐ No ICU Admission? ☐ Yes ☐ No
Other Symptoms:
Risk/Exposure:
NOTE: Non-hospitalized patients should remain in home isolation until laboratory results are available.
**See below for specimen collection and shipping instructions**
**Samples collected or shipped not in accordance with below instructions will be unsatisfactory for testing**
Temp:
Clinician Signature: Date:
By signing this form you are agreeing that this person meets Kansas PUI criteria for testing. This form can be digitally signed.
**Collection Date is Required**
Zip:
KDHE Coronavirus Disease 2019 (COVID-19) Testing
Kansas COVID-19 PUI Criteria, Testing Form, and Shipping Guidance (03/18/2020)
Specimen Collection and Shipping Instructions
• Fill out the above KDHE Coronavirus Disease 2019 (COVID-19) Testing Form above. Include
a copy of the form with the specimen shipment. Fax the form to 877-427-7318.
• Collect a nasopharyngeal (NP) swab using a synthetic fiber swab with plastic shaft (not
wooden)
o Insert swab into the nostril parallel to the palate. Leave the swab in place for a few
seconds to absorb secretions. An instructional video for NP swab collection can be
found at KDHE COVID-19 webpage.
• Label the specimen container with the patient’s name and specimen type.
• The NP swab should be placed in 2-3 mL of Viral Transport Media (VTM). If VTM is not
available, sterile saline is acceptable.
• Ensure the specimen tube is tight and will not leak.
• Place NP swab into its own 95 kPa bag. Ensure that sufficient absorbent material is present in
specimen transport bags.
• Place all specimens in resealable zip-top biohazard bag.
• Store specimens at 2-8⁰C and ship overnight on ice packs as a Category B infectious
substance.
o Rapid shipping is important - specimens must be tested within 72 hours of specimen
collection. Ship overnight. Use a weekend delivery option if shipping near the weekend.
• Ship to
o Kansas Health and Environmental Laboratories
o 6810 SE Dwight St, Topeka, KS 66620
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Completed 26 March 2020

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