Instructions for Form 1198, SARS-CoV-2 (Virus that causes COVID-19) Testing Requisition
Purpose
To collect submitter information, patient demographics and specimen information for isolates submitted for SARS-
CoV-2 (Virus that causes COVID-19) testing.
Instructions:
Submitter Information- Left hand side of requisition
Record all requested information
Patient ID Number: Enter the submitter’s patient identification number.
Submitter Name: Enter the submitting facility’s full name.
Street Address: Enter the submitting facility’s street address
City: Enter the submitting facility’s city
State: Enter the submitting facility’s state
Zip: Enter the submitting facility’s zip code
Phone Number: Enter the submitting facility’s phone number
Contact Name: Enter the name of the submitting facility’s contact if applicable
Contact: Enter the phone number of the submitting facility’s contact if applicable
Patient Information – Right hand of requisition
Patient Name- Enter the patient's LAST NAME, FIRST NAME AND MIDDLE INITIAL
in sequence. The spelling of the name on the laboratory slip and the specimen
container/tube must be identical. Name listed must be legal name; DO NOT use nicknames.
County of Residence- Enter the county where the patient currently resides (Hinds, Rankin, etc).
Date of Birth- Provide in MM/DD/YY format.
Address - Enter the complete address where the patient currently resides.
City - Enter the name of the city in which the patient resides.
State - Enter the state in which the patient resides
Zip Code - Enter the Zip Code of the patient's address.
Phone Number – Enter patient’s telephone number including area code.
Specimen Type: Submit a NP swab and an OP swab for each patient. If patient has a productive cough, submit one
Lower Respiratory Specimen in addition to NP and OP swabs. Provide the Date of collection in MM/DD/YY format
Test Requested: Check the box by the appropriate test requested.
Race – Check the box associated with the patient's race
Ethnicity- Check the appropriate box
Gender- Check the appropriate box (male or female)
Required Epidemiological Information: Respond Yes or No to all questions. Provide all applicable information
requested.
Office Mechanics and Filing – This form must accompany each patient for whom specimens are submitted to the
MSDH Laboratory. A copy should be retained by the submitter as documentation of submission. Test results will be
reported via computer generated report and forwarded to the submitter.
Retention Period – The MSDH Laboratory will retain the original form in accordance with Clinical Laboratory
Improvement Amendments (CLIA) regulations.
Mississippi State Department of Health 6/12/20 Revision Form 1198