COVID-19 Testing Through Public Health 
  CLINICIAN INFORMATION
Only complete this form if you are able to and intend to collect specimens and submit them to the Georgia Public Health Laboratory for testing.

If you are submitting specimens elsewhere (i.e. commercial laboratory or hospital laboratory) or are unable to collect specimens, you do not need to complete this form.
1 . Georgia Public Health Lab Submitter Code
2 . Hospital/Facility Name
3 . Hospital/Facility Street Address
4 . Hospital/Facility City
5 . Hospital/Facility State
6 . Hospital/Facility Zip
7 . Hospital/Facility Phone--
8 . Hospital/Facility Fax--
9 . Facility Email (POINT OF CONTACT FOR ALL SUBSEQUENT COMMUNICATION- INLCUDING RESULTS!) Please ensure this email is correct!
10 . Facility Contact Name
11 . Date/Time of form submission:
  PATIENT INFORMATION
1 . Patient ID Number
2 . Last Name
3 . First Name
4 . Date of Birth//
5 . Street Address
6 . City
7 . County
8 . State
9 . Zip Code
10 . Phone--
11 . GenderFemale Male 
12 . Race
13 . EthnicityHispanic Or Latino  Non-Hispanic Or Latino Unknown 
14 . Did the patient die?Yes No 
15 . If yes, date of death//
  SPECIMEN INFORMATION
1 . Date of Collection//
2 . Time of Collection:AMPM
3 . Specimen type
         Nasal Swab
         Nasopharyngeal swab
         Comb. Nasopharyngeal/ Oropharyngeal swab
         Postmortem lung swab
         Formalin-fixed autopsy tissues
         Bronchoalveolar Lavage (BAL)
         Tracheal Aspirate
         Sputum
4 . ShippedFrozen Refrigerated 
  PATIENT RISK FACTORS
1 . Does this patient have symptoms consistent with COVID-19 (fever, cough, shortness of breath)?Yes No Unknown 
2 . If yes, date of symptom onset://
3 . Does the patient fall into any of the following groups? (select all that apply)
       Currently Pregnant
       Have Any Pre-existing Medical Conditions
       Currently Hospitalized
       First Responder
       Healthcare Worker
       Work Or Live In A Long-Term Care Or Assisted Living Facility
       Work Or Live In A Jail Or Prison
       Work In A Poultry/Meat Processing Plant
       Work Or Live In A Congregate Setting Other Than A Long-Term Care, Assisted Living Facility, or jail/prison (Ex. Shelter, Mental Health Inpatient, Rehab Inpatient)
       Contact With A Case (Confirmed Or Suspect)
       Close Contact Of A Person In A High Risk Group (Ex. Household Member Of Healthcare Worker Or First Responder)
       Unknown
       None
4 . Is this case part of an outbreak?Yes No Unknown 
5 . If yes, outbreak ID:
6 . Any comments, including name of long-term care facility or other congregate setting if available.
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