County of Santa Cruz
HEALTH SERVICES AGENCY
PO BOX 962, 1060 EMELINE AVE., SANTA CRUZ, CA 95061-0962
PHONE: (831) 454-4114 AFTER HOURS: (831) 471-1170 FAX: (831) 454-5049 TDD: (831) 454-4123
COMMUNICABLE DISEASE UNIT (CDU)
Revised 2/1/2017
ZIKA VIRUS SCREENING FORM FOR SPECIMEN SUBMITTAL
PATIENT INFORMATION
PATIENT’S NAME (Last, First):
PREGNANT?
NO YES, Due Date:
ADDRESS (include ZIP code):
ETHNICITY:
Hispanic
Non-Hispanic
RACE:
White Black
Asian Other: ________
SIGNS / SYMPTOMS?
NO YES
If YES, DATE OF ONSET:
Zika-like SYMPTOMS:
Fever
Rash
Joint Pain
Conjunctivitis
Other:
RISK HISTORY:
Did patient travel to an area with active Zika
transmission* within the 2 weeks prior to onset of
symptoms? N Y
If patient is pregnant, did they travel to an area
with active Zika transmission* in the last 2-12
weeks? N Y
Did the patient have unprotected sex with
someone who traveled to or resides in an area
with active Zika transmission*? N Y, Last
date of unprotected sex (estimate):_________
Despite the recommendation to have protected
sex if partner had possible zika exposure, is
patient having ongoing unprotected sex?
N Y
Did the unprotected sex partner have Zika
symptoms? N Y, ONSET Date:
Has patient received a Yellow Fever vaccine?
N Y Unk
TRAVEL DETAILS:
PATIENT TRAVEL to (Countries & Cities):
Dates of Travel: to
SEX PARTNER TRAVEL to (Countries & Cities):
Dates of Travel: to
* Please see implicated areas here:
http://www.cdc.gov/zika/geo/index.html
SUBMITTER INFORMATION
INSTRUCTIONS
Please complete and fax this form to the Santa Cruz County Public Health CDU at (831) 454-5049 for staff to evaluate the
need for lab testing. Specimens that have not been cleared by CDU will not be accepted for transport to the State labs.
If testing is indicated and approval for testing has been granted from the CDU, blood and/or urine samples can be collected
at Santa Cruz County Public Health Laboratory (PHL) at 1080 Emeline Avenue, Santa Cruz, between the hours of 8 AM and
4:30 PM (4:00 PM on Fridays). The lab is closed for lunch between 12:30 and 1:00 PM.
Our local PHL will ship specimens directly to the CDPH Viral and Rickettsial Disease Laboratory (VRDL). VRDL personnel will
forward specimens on to the CDC as appropriate, and the VRDL will track and report testing results.
When requesting laboratory testing for Zika virus, there is no need to order multiple tests (such as for Dengue, West Nile
virus, etc.). A full panel of tests will be performed, with follow-up testing as indicated. (“Arbovirus” or “arbovirus panel”
may be used to order.)
Please call the CDU for further questions at (831) 454-4114.
