Amhara Public Health Institute
Document No: APHI/VRL/SOP-5.4-03
Version No: 01
COVID-19 virus Laboratory Page No.: 01 of 01
test request form Effective Date: 02/03/2020
Laboratory testing for coronavirus disease 2019 (COVID-19) in suspected
human cases
COVID-19 virus Laboratory test request form
Submitter information
Name of submitting Hospital, Laboratory, or
other facility
Physician/Clinician
Address
Phone number
Case definition ☐ Suspect case ☐ Probable case
Patient information
First name Last Name
Patient ID number Date of Age
Birth
Address Sex ☐ Male ☐ Female
Phone number
Specimen information
Type ☐ 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 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 Time of
collection collection
Priority status
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Amhara Public Health Institute
Document No: APHI/VRL/SOP-5.4-03
Version No: 01
COVID-19 virus Laboratory Page No.: 01 of 01
test request form Effective Date: 02/03/2020
xxxx~Paste: from request form/to this report form:
Please tick the box if your clinical sample is post mortem ☐
Date of collection Time of collection
Priority status
Clinical details
Does the patient have history of ☐ Yes ☐ No - If yes, Date of onset: ___________________
clinical symptoms? - If Yes, specify symptoms: ______________________________
Has the patient had a recent history of ☐ Yes ☐ No If yes, Country/Place ____________________
travelling to an affected area? Return Date ___________________________
Has the patient had contact with a ☐ Yes ☐ No ☐ Unknown ☐ Other exposure: _____________
confirmed case?
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xxx~Paste from Lab *report form:
Lab Diagnosis
Lab S.No# __________________
Test Protocol_____________________________Test Method __________________________
Test Result _______________________________________________________
Test done by ___________________________Sign______________Date__________________
Test approved and reported by _______________________Sign_________Date_____________
