Get Human Arbovirus Specimen Submission Form

Completing the Human Arbovirus Specimen Submission Form online is a vital step for health care providers to submit samples for arbovirus testing. This guide will walk you through each section of the form to ensure a smooth and accurate submission process.

Follow the steps to complete the form correctly

1. Press the ‘Get Form’ button to access the Human Arbovirus Specimen Submission Form and open it in your preferred editing program.
2. In the 'Case Name' field, input the name of the person for whom the specimen is being submitted. Fill in the 'Parent Name' if applicable. Enter the 'Town of Residence' and a valid 'Home Number'. Also, indicate their date of birth or age in the corresponding section.
3. Provide the person's gender and race/ethnicity in their respective fields. If the person resides in a residential facility, include the contact name and phone number.
4. Complete the 'Clinical Information' section by entering your name as the person completing the form, along with your title and the health care provider's name. Also, provide a contact phone number.
5. Indicate whether the sample was taken in the emergency department by selecting 'Yes' or 'No'. If yes, please specify the hospital name. If the person was hospitalized, complete the relevant sections, including admission and discharge dates.
6. Fill in the symptom onset date. Respond to the symptom questions by indicating 'Yes' or 'No' for each listed symptom, including fever, headache, and any others relevant to the condition.
7. For the section regarding the information on specimens being submitted, choose 'Yes' or 'No' for 'Acute Blood', 'Convalescent Blood', and 'CSF'. Include collection dates as needed.
8. The form contains a section designated for Maine CDC staff to complete. Leave this section blank as it will be filled out by the appropriate personnel.
9. Once all fields are filled accurately, save your changes. You can download a copy of the form, print it for your records, or share it with the appropriate parties.

Complete your Human Arbovirus Specimen Submission Form online today.