+-----------------------+----------------------------------------------+
| ![](media             | # HUMAN CASES                                |
| /image1.jpeg){width=" |                                              |
| 2.1868055555555554in" | # INTERIM FIELD SPECIMEN COLLECTION FORM     |
| height="1             |                                              |
| .5923611111111111in"} | # ACCESSIONING FORM                          |
|                       |                                              |
|                       | ##### CDC/NCID/POXVIRUS SECTION              |
|                       |                                              |
|                       | ###### 1600 CLIFTON ROAD MS G-18             |
|                       |                                              |
|                       | ATLANTA, GA 30333                            |
|                       |                                              |
|                       | ## TEL: (404) 639-4931 FAX: (404) 639-3111   |
+-----------------------+----------------------------------------------+

### NI = No information available State or Local ID# \_\_\_\_\_\_\_\_\_\_\_\_ CDC Pox unique ID# \_\_\_\_\_\_\_\_\_\_

+-----------------------------------+-----------------------------------+
| #### CASE NUMBER                  | *DATE RECEIVED*                   |
|                                   |                                   |
| *(Poxvirus Lab use only)*         |                                   |
+-----------------------------------+-----------------------------------+
|                                   | \_\_\_\_\_\_\_\_\_\_/\_\_         |
|                                   | \_\_\_\_\_\_/\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+-----------------------------------+
| Consultation with the state       |                                   |
| epidemiologist                    |                                   |
| ([www.cste.org                    |                                   |
| /members/state_and_territorial_ep |                                   |
| i.asp](http://www.cste.org/member |                                   |
| s/state_and_territorial_epi.asp)) |                                   |
| and state health laboratory       |                                   |
| ([www.aphl.org/public_health_     |                                   |
| labs/index.cfm](http://www.aphl.o |                                   |
| rg/public_health_labs/index.cfm)) |                                   |
| is necessary for submission       |                                   |
| instructions before sending       |                                   |
| specimens to CDC.                 |                                   |
+-----------------------------------+-----------------------------------+

+-----------------------------------+-----------------------------------+
| *PATIENT INFORMATION*             | *PROVIDER INFORMATION (SUBMITTED  |
|                                   | BY)*                              |
+-----------------------------------+-----------------------------------+
| ![](media/image2.wmf)CLINICAL     | LAST                              |
| !                                 | NAME:\_\_\_\_\_\_\_\_\_\_\_\_\    |
| [](media/image3.wmf)ENVIRONMENTAL | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                   |                                   |
| Last                              | FIRST                             |
| Name:\_\_\_\_\_\_\_\_\_\_\_\_\    | NAME:\_\_\_\_\_\_\_\_\_\_\_\_\    |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                   |                                   |
| First                             | ADDRES                            |
| Name:\_\_\_\_\_\_\_\_\_\_\_\_\    | S:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                   |                                   |
| CITY:\_\_\_                       | \_\_\_\_\_\_\_\_                  |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                   |                                   |
| STATE:\_\_                        | CITY:\_\_\_                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                   |                                   |
| COUNTY:                           | STATE:\_\_                        |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                   |                                   |
| ZIP                               | COUNTY:                           |
| COD                               | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| E:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |                                   |
|                                   | ZIP                               |
| COUN                              | COD                               |
| TRY:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ | E:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                   |                                   |
| SPECIES (If other than            | COUN                              |
| huma                              | TRY:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| n):\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                   |                                   |
| SEX: M / F / NI                   | TE                                |
| DOB:\_\_\_\_/\_\_\_\_/\_\_\_\_\_  | LEPHONE:\_(\_\_\_\_\_)\_\_\_\_\_\ |
| NI                                | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                   |                                   |
| HOSPITAL PATIENT NUMBER:          | TEL                               |
| \_\_\_\_\_\_\_\_\_\_\_\_          | 2:\_\_                            |
|                                   | (\_\_\_\_)\_\_\_\_\_\_\_\_\_\_\_\ |
|                                   | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                   |                                   |
|                                   | FAX:                              |
|                                   | \_(\_\                            |
|                                   | _\_\_\_\_)\_\_\_\_\_\_\_\_\_\_\_\ |
|                                   | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                   |                                   |
|                                   | EMAIL:\_\_                        |
|                                   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
|                                   | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                   |                                   |
|                                   | ### DATE CASE IDENTIFIED:         |
|                                   |  \_\_\_\_\_\_/\_\_\_\_/\_\_\_\_\_ |
+-----------------------------------+-----------------------------------+

+-----------------------------------------------------------------------+
| ### CLINICAL HISTORY                                                  |
+-----------------------------------------------------------------------+
| PATIENT HOSPITALIZED? Y / N / NI                                      |
|                                                                       |
| OUTCOME? RECOVERED DIED DATE OF                                       |
| DEATH:\_\_\_\_\_\_/\_\_\_\_/\_\_\_\_\_\_ NI                           |
|                                                                       |
| FEVER: Y / N / NI FEVER ONSET DATE:\_\_\_\_\_\_/\_\_\_\_/\_\_\_\_\_\_ |
|                                                                       |
| RASH: Y / N / NI RASH ONSET DATE: \_\_\_\_\_\_/\_\_\_\_/\_\_\_\_\_\_  |
|                                                                       |
| LESION TYPE: \_\_\_\_\_\_MACULES APPROX                               |
| NUMBER:\_\_\_\_\_\_\_\_LOCATION:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_        |
|                                                                       |
| \_\_\_\_\_\_PAPULES APPROX                                            |
| NUMBER:\_\_\_\_\_\_\_\_LOCATION:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_        |
|                                                                       |
| \_\_\_\_\_\_VESICLES APPROX                                           |
| NUMBER:\_\_\_\_\_\_\_\_LOCATION:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_        |
|                                                                       |
| \_\_\_\_\_\_PUSTULES APPROX                                           |
| NUMBER:\_\_\_\_\_\_\_\_LOCATION:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_      |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| ### VACCINE HISTORY                                                   |
+-----------------------------------------------------------------------+
| HAS THE PATIENT EVER HAD SMALLPOX? Y / N /                            |
|                                                                       |
| HAS THE PATIENT EVER RECEIVED THE VACCINIA (SMALLPOX) VACCINE? Y / N  |
| /                                                                     |
|                                                                       |
| VACCINATION DATE                                                      |
| 1:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_VACCINATION DATE    |
| 2:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                  |
|                                                                       |
| DOES THE PATIENT HAVE A VACCINATION SCAR? Y / N /                     |
|                                                                       |
| HAS THE PATIENT EVER HAD CHICKENPOX? Y / N /                          |
|                                                                       |
| HAS THE PATIENT RECEIVED THE VARICELLA VACCINE? Y / N / VACCINATION   |
| DATE 1:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_VACCINATION    |
| DATE 2:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_             |
|                                                                       |
| WAS THE PATIENT RECENTLY EXPOSED TO SMALLPOX? Y / N / NI \# OF DAYS   |
| AGO:\_\_\_\_\_\_\_                                                    |
|                                                                       |
| CHICKENPOX? Y / N / NI \# OF DAYS AGO:\_\_\_\_\_\_\_                  |
|                                                                       |
| DID THE PATIENT TAKE STEROIDS OR IMMUNOSUPPRESSANT DRUGS DURING THE   |
| MONTH PRIOR TO THE RASH ONSET? Y / N / NI                             |
+-----------------------------------------------------------------------+

  -----------------------------------------------------------------------
  *ADDITIONAL CLINICAL OBSERVATIONS AND BRIEF PATIENT HISTORY*

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------
  *DIAGNOSTIC NOTES*

  -----------------------------------------------------------------------

+-----------------------------------------------------------------------+
| ### CLINICAL DIAGNOSIS                                                |
+-----------------------------------------------------------------------+
| \_\_\_\_\_\_ORTHOPOX                                                  |
|                                                                       |
| \_\_\_\_\_\_VACCINIA                                                  |
|                                                                       |
| \_\_\_\_\_\_MONKEYPOX                                                 |
|                                                                       |
| \_\_\_\_\_\_VARIOLA                                                   |
|                                                                       |
| \_\_\_\_\_\_VARICELLA                                                 |
|                                                                       |
| \_\_\_\_\_\_VARICELLA ZOSTER                                          |
|                                                                       |
| \_\_\_\_\_\_COWPOX                                                    |
|                                                                       |
| \_\_\_\_\_\_OTHER                                                     |
| SPECIFY:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| *INVESTIGATOR INFORMATION*                                            |
|                                                                       |
| *(Person submitting case history and specimens)*                      |
+-----------------------------------------------------------------------+
| LAST                                                                  |
| NAME:\_\_\_\_                                                         |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| FIRST                                                                 |
| NAME:\_\_\_                                                           |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| TITLE:\_\_\_\_\_\_\_\_\_\_                                            |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| ORGANIZATION:                                                         |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| ADDRESS:\_\_\_\_\_\_                                                  |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| CITY:\_\_\_\_\_                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_STATE:\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ZIP:\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| TELEPHONE:\_\_( )\_\_\_\_\_\_\_-\_\_\_\_\_\_\_\_\_\_\_\_FAX:\_\_(     |
| )\_\_\_\_\_\_\_\_-\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                      |
|                                                                       |
| EMAIL:\_\_\_\_\_\_\_\_\_                                              |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| #### SPECIMEN MATERIAL                                                |
+-----------------------------------------------------------------------+
| DATE COLLECTED:\_\_\_\_\_\_\_\_/\_\_\_\_\_\_\_\_/\_\_\_\_\_\_\_\_     |
|                                                                       |
| **DASH NUMBER:**                                                      |
|                                                                       |
| **[SAMPLE MATERIAL]{.underline} [METHOD]{.underline} ASTRO:**         |
|                                                                       |
| \_\_\_MACULE/PAPULE                                                   |
|                                                                       |
| \_\_\_VESICLE SKIN \_\_\_\_ SWAB                                      |
|                                                                       |
| \_\_\_VESICLE FLUID \_\_\_\_SLIDE **BRRAT:**                          |
|                                                                       |
| \_\_\_PUSTULE SKIN \_\_\_\_VACUTAINER                                 |
|                                                                       |
| \_\_\_PUSTULE FLUID \_\_\_\_CONTAINER                                 |
|                                                                       |
| \_\_\_CRUST \_\_\_\_EM GRID                                           |
|                                                                       |
| \_\_\_OROPHARYNGEAL TISSUE \_\_\_\_TOUCHPREP **BT NUMBER:**           |
|                                                                       |
| \_\_\_OTHER TISSUE \_\_\_\_BIOPSY/ FORMALIN                           |
|                                                                       |
| \_\_\_CSF \_\_\_\_BIOPSY/ DRY                                         |
|                                                                       |
| \_\_\_BLOOD                                                           |
|                                                                       |
| \_\_\_SERUM                                                           |
|                                                                       |
| \_\_\_OTHER                                                           |
|                                                                       |
| \_\_\_NO INFORMATION ANATOMICAL                                       |
| SITE:\_\                                                              |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------------------------------------------+
| #### SPECIMEN MATERIAL                                                |
+-----------------------------------------------------------------------+
| DATE COLLECTED:\_\_\_\_\_\_\_\_/\_\_\_\_\_\_\_\_/\_\_\_\_\_\_\_\_     |
|                                                                       |
| **DASH NUMBER:**                                                      |
|                                                                       |
| **[SAMPLE MATERIAL]{.underline} [METHOD]{.underline} ASTRO:**         |
|                                                                       |
| \_\_\_MACULE/PAPULE                                                   |
|                                                                       |
| \_\_\_VESICLE SKIN \_\_\_\_ SWAB                                      |
|                                                                       |
| \_\_\_VESICLE FLUID \_\_\_\_SLIDE **BRRAT:**                          |
|                                                                       |
| \_\_\_PUSTULE SKIN \_\_\_\_VACUTAINER                                 |
|                                                                       |
| \_\_\_PUSTULE FLUID \_\_\_\_CONTAINER                                 |
|                                                                       |
| \_\_\_CRUST \_\_\_\_EM GRID                                           |
|                                                                       |
| \_\_\_OROPHARYNGEAL TISSUE \_\_\_\_TOUCHPREP **BT NUMBER:**           |
|                                                                       |
| \_\_\_OTHER TISSUE \_\_\_\_BIOPSY/ FORMALIN                           |
|                                                                       |
| \_\_\_CSF \_\_\_\_BIOPSY/ DRY                                         |
|                                                                       |
| \_\_\_BLOOD                                                           |
|                                                                       |
| \_\_\_SERUM                                                           |
|                                                                       |
| \_\_\_OTHER                                                           |
|                                                                       |
| \_\_\_NO INFORMATION ANATOMICAL                                       |
| SITE:\_\                                                              |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------------------------------------------+
| #### SPECIMEN MATERIAL                                                |
+-----------------------------------------------------------------------+
| DATE COLLECTED:\_\_\_\_\_\_\_\_/\_\_\_\_\_\_\_\_/\_\_\_\_\_\_\_\_     |
|                                                                       |
| **DASH NUMBER:**                                                      |
|                                                                       |
| **[SAMPLE MATERIAL]{.underline} [METHOD]{.underline} ASTRO:**         |
|                                                                       |
| \_\_\_MACULE/PAPULE                                                   |
|                                                                       |
| \_\_\_VESICLE SKIN \_\_\_\_ SWAB                                      |
|                                                                       |
| \_\_\_VESICLE FLUID \_\_\_\_SLIDE **BRRAT:**                          |
|                                                                       |
| \_\_\_PUSTULE SKIN \_\_\_\_VACUTAINER                                 |
|                                                                       |
| \_\_\_PUSTULE FLUID \_\_\_\_CONTAINER                                 |
|                                                                       |
| \_\_\_CRUST \_\_\_\_EM GRID                                           |
|                                                                       |
| \_\_\_OROPHARYNGEAL TISSUE \_\_\_\_TOUCHPREP **BT NUMBER:**           |
|                                                                       |
| \_\_\_OTHER TISSUE \_\_\_\_BIOPSY/ FORMALIN                           |
|                                                                       |
| \_\_\_CSF \_\_\_\_BIOPSY/ DRY                                         |
|                                                                       |
| \_\_\_BLOOD                                                           |
|                                                                       |
| \_\_\_SERUM                                                           |
|                                                                       |
| \_\_\_OTHER                                                           |
|                                                                       |
| \_\_\_NO INFORMATION ANATOMICAL                                       |
| SITE:\_\                                                              |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| #### SPECIMEN MATERIAL                                                |
+-----------------------------------------------------------------------+
| DATE COLLECTED:\_\_\_\_\_\_\_\_/\_\_\_\_\_\_\_\_/\_\_\_\_\_\_\_\_     |
|                                                                       |
| **DASH NUMBER:**                                                      |
|                                                                       |
| **[SAMPLE MATERIAL]{.underline} [METHOD]{.underline} ASTRO:**         |
|                                                                       |
| \_\_\_MACULE/PAPULE                                                   |
|                                                                       |
| \_\_\_VESICLE SKIN \_\_\_\_ SWAB                                      |
|                                                                       |
| \_\_\_VESICLE FLUID \_\_\_\_SLIDE **BRRAT:**                          |
|                                                                       |
| \_\_\_PUSTULE SKIN \_\_\_\_VACUTAINER                                 |
|                                                                       |
| \_\_\_PUSTULE FLUID \_\_\_\_CONTAINER                                 |
|                                                                       |
| \_\_\_CRUST \_\_\_\_EM GRID                                           |
|                                                                       |
| \_\_\_OROPHARYNGEAL TISSUE \_\_\_\_TOUCHPREP **BT NUMBER:**           |
|                                                                       |
| \_\_\_OTHER TISSUE \_\_\_\_BIOPSY/ FORMALIN                           |
|                                                                       |
| \_\_\_CSF \_\_\_\_BIOPSY/ DRY                                         |
|                                                                       |
| \_\_\_BLOOD                                                           |
|                                                                       |
| \_\_\_SERUM                                                           |
|                                                                       |
| \_\_\_OTHER                                                           |
|                                                                       |
| \_\_\_NO INFORMATION ANATOMICAL                                       |
| SITE:\_\                                                              |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------------------------------------------+
| #### SPECIMEN MATERIAL                                                |
+-----------------------------------------------------------------------+
| DATE COLLECTED:\_\_\_\_\_\_\_\_/\_\_\_\_\_\_\_\_/\_\_\_\_\_\_\_\_     |
|                                                                       |
| **DASH NUMBER:**                                                      |
|                                                                       |
| **[SAMPLE MATERIAL]{.underline} [METHOD]{.underline} ASTRO:**         |
|                                                                       |
| \_\_\_MACULE/PAPULE                                                   |
|                                                                       |
| \_\_\_VESICLE SKIN \_\_\_\_ SWAB                                      |
|                                                                       |
| \_\_\_VESICLE FLUID \_\_\_\_SLIDE **BRRAT:**                          |
|                                                                       |
| \_\_\_PUSTULE SKIN \_\_\_\_VACUTAINER                                 |
|                                                                       |
| \_\_\_PUSTULE FLUID \_\_\_\_CONTAINER                                 |
|                                                                       |
| \_\_\_CRUST \_\_\_\_EM GRID                                           |
|                                                                       |
| \_\_\_OROPHARYNGEAL TISSUE \_\_\_\_TOUCHPREP **BT NUMBER:**           |
|                                                                       |
| \_\_\_OTHER TISSUE \_\_\_\_BIOPSY/ FORMALIN                           |
|                                                                       |
| \_\_\_CSF \_\_\_\_BIOPSY/ DRY                                         |
|                                                                       |
| \_\_\_BLOOD                                                           |
|                                                                       |
| \_\_\_SERUM                                                           |
|                                                                       |
| \_\_\_OTHER                                                           |
|                                                                       |
| \_\_\_NO INFORMATION ANATOMICAL                                       |
| SITE:\_\                                                              |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------------------------------------------+
| #### SPECIMEN MATERIAL                                                |
+-----------------------------------------------------------------------+
| DATE COLLECTED:\_\_\_\_\_\_\_\_/\_\_\_\_\_\_\_\_/\_\_\_\_\_\_\_\_     |
|                                                                       |
| **DASH NUMBER:**                                                      |
|                                                                       |
| **[SAMPLE MATERIAL]{.underline} [METHOD]{.underline} ASTRO:**         |
|                                                                       |
| \_\_\_MACULE/PAPULE                                                   |
|                                                                       |
| \_\_\_VESICLE SKIN \_\_\_\_ SWAB                                      |
|                                                                       |
| \_\_\_VESICLE FLUID \_\_\_\_SLIDE **BRRAT:**                          |
|                                                                       |
| \_\_\_PUSTULE SKIN \_\_\_\_VACUTAINER                                 |
|                                                                       |
| \_\_\_PUSTULE FLUID \_\_\_\_CONTAINER                                 |
|                                                                       |
| \_\_\_CRUST \_\_\_\_EM GRID                                           |
|                                                                       |
| \_\_\_OROPHARYNGEAL TISSUE \_\_\_\_TOUCHPREP **BT NUMBER:**           |
|                                                                       |
| \_\_\_OTHER TISSUE \_\_\_\_BIOPSY/ FORMALIN                           |
|                                                                       |
| \_\_\_CSF \_\_\_\_BIOPSY/ DRY                                         |
|                                                                       |
| \_\_\_BLOOD                                                           |
|                                                                       |
| \_\_\_SERUM                                                           |
|                                                                       |
| \_\_\_OTHER                                                           |
|                                                                       |
| \_\_\_NO INFORMATION ANATOMICAL                                       |
| SITE:\_\                                                              |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| #### SPECIMEN MATERIAL                                                |
+-----------------------------------------------------------------------+
| DATE COLLECTED:\_\_\_\_\_\_\_\_/\_\_\_\_\_\_\_\_/\_\_\_\_\_\_\_\_     |
|                                                                       |
| **DASH NUMBER:**                                                      |
|                                                                       |
| **[SAMPLE MATERIAL]{.underline} [METHOD]{.underline} ASTRO:**         |
|                                                                       |
| \_\_\_MACULE/PAPULE                                                   |
|                                                                       |
| \_\_\_VESICLE SKIN \_\_\_\_ SWAB                                      |
|                                                                       |
| \_\_\_VESICLE FLUID \_\_\_\_SLIDE **BRRAT:**                          |
|                                                                       |
| \_\_\_PUSTULE SKIN \_\_\_\_VACUTAINER                                 |
|                                                                       |
| \_\_\_PUSTULE FLUID \_\_\_\_CONTAINER                                 |
|                                                                       |
| \_\_\_CRUST \_\_\_\_EM GRID                                           |
|                                                                       |
| \_\_\_OROPHARYNGEAL TISSUE \_\_\_\_TOUCHPREP **BT NUMBER:**           |
|                                                                       |
| \_\_\_OTHER TISSUE \_\_\_\_BIOPSY/ FORMALIN                           |
|                                                                       |
| \_\_\_CSF \_\_\_\_BIOPSY/ DRY                                         |
|                                                                       |
| \_\_\_BLOOD                                                           |
|                                                                       |
| \_\_\_SERUM                                                           |
|                                                                       |
| \_\_\_OTHER                                                           |
|                                                                       |
| \_\_\_NO INFORMATION ANATOMICAL                                       |
| SITE:\_\                                                              |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------------------------------------------+
| #### SPECIMEN MATERIAL                                                |
+-----------------------------------------------------------------------+
| DATE COLLECTED:\_\_\_\_\_\_\_\_/\_\_\_\_\_\_\_\_/\_\_\_\_\_\_\_\_     |
|                                                                       |
| **DASH NUMBER:**                                                      |
|                                                                       |
| **[SAMPLE MATERIAL]{.underline} [METHOD]{.underline} ASTRO:**         |
|                                                                       |
| \_\_\_MACULE/PAPULE                                                   |
|                                                                       |
| \_\_\_VESICLE SKIN \_\_\_\_ SWAB                                      |
|                                                                       |
| \_\_\_VESICLE FLUID \_\_\_\_SLIDE **BRRAT:**                          |
|                                                                       |
| \_\_\_PUSTULE SKIN \_\_\_\_VACUTAINER                                 |
|                                                                       |
| \_\_\_PUSTULE FLUID \_\_\_\_CONTAINER                                 |
|                                                                       |
| \_\_\_CRUST \_\_\_\_EM GRID                                           |
|                                                                       |
| \_\_\_OROPHARYNGEAL TISSUE \_\_\_\_TOUCHPREP **BT NUMBER:**           |
|                                                                       |
| \_\_\_OTHER TISSUE \_\_\_\_BIOPSY/ FORMALIN                           |
|                                                                       |
| \_\_\_CSF \_\_\_\_BIOPSY/ DRY                                         |
|                                                                       |
| \_\_\_BLOOD                                                           |
|                                                                       |
| \_\_\_SERUM                                                           |
|                                                                       |
| \_\_\_OTHER                                                           |
|                                                                       |
| \_\_\_NO INFORMATION ANATOMICAL                                       |
| SITE:\_\                                                              |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------------------------------------------+
| #### SPECIMEN MATERIAL                                                |
+-----------------------------------------------------------------------+
| DATE COLLECTED:\_\_\_\_\_\_\_\_/\_\_\_\_\_\_\_\_/\_\_\_\_\_\_\_\_     |
|                                                                       |
| **DASH NUMBER:**                                                      |
|                                                                       |
| **[SAMPLE MATERIAL]{.underline} [METHOD]{.underline} ASTRO:**         |
|                                                                       |
| \_\_\_MACULE/PAPULE                                                   |
|                                                                       |
| \_\_\_VESICLE SKIN \_\_\_\_ SWAB                                      |
|                                                                       |
| \_\_\_VESICLE FLUID \_\_\_\_SLIDE **BRRAT:**                          |
|                                                                       |
| \_\_\_PUSTULE SKIN \_\_\_\_VACUTAINER                                 |
|                                                                       |
| \_\_\_PUSTULE FLUID \_\_\_\_CONTAINER                                 |
|                                                                       |
| \_\_\_CRUST \_\_\_\_EM GRID                                           |
|                                                                       |
| \_\_\_OROPHARYNGEAL TISSUE \_\_\_\_TOUCHPREP **BT NUMBER:**           |
|                                                                       |
| \_\_\_OTHER TISSUE \_\_\_\_BIOPSY/ FORMALIN                           |
|                                                                       |
| \_\_\_CSF \_\_\_\_BIOPSY/ DRY                                         |
|                                                                       |
| \_\_\_BLOOD                                                           |
|                                                                       |
| \_\_\_SERUM                                                           |
|                                                                       |
| \_\_\_OTHER                                                           |
|                                                                       |
| \_\_\_NO INFORMATION ANATOMICAL                                       |
| SITE:\_\                                                              |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------------------------------------------+