ICMR Specimen Referral Form for COVID-19 (18-09-2020)- Kerala

This form is for collection centres/ labs to enter details of the samples being tested for Covid-19. It is mandatory to fill this form for each and every sample being tested. It is essential that the collection centres/ labs exercise caution to ensure that correct information is captured in the form. Fields marked with asterisk (*) are mandatory to be filled.

PERSONAL DETAILS


TEST INITIATION DETAILS

SPECIMEN INFORMATION FROM REFERRING AGENCY


PATIENT CATEGORY (PLEASE SELECT ONLY ONE)

Routine surveillance in containment zones and screening at points of entry

Routine surveillance in non-containment areas

In Hospital Settings

Testing on demand


CLINICAL SYMPTOMS AND SIGNS




PRE-EXISTING MEDICAL CONDITIONS



  

HOSPITALIZATION DETAILS


REFERRING DOCTOR DETAILS