SARS-CoV-2/Influenza Specimen Submission Form

Complete fields and click GENERATE PDF at the bottom of the page to create a PDF to submit with specimen.

Data entered on this page are not electronically transferred to testing laboratories. Please log in (using the button on the top right-hand corner) to the authenticated portal if that functionality is needed.

Approval required prior to submission to ODHL – contact 614-995-5599, option 1.
Fields marked with an asterisk (*) must be completed.

Please fix the following errors

Patient Information

Patient Name First MI Last

Date of Birth

Use Submitter Address

Sex Female Male

Phone Number

Address

Chart or Patient ID#

City

State

Zip

County

Race

White Black/African American Asian Native Hawaiian/Pacific Islander American Indian/Alaskan Native Other

Ethnicity

Hispanic Non-Hispanic

Submitter Information

Agency Name

Contact Name

Address

Secure Fax Number

City

State

Zip

Phone Number

Specimen Information

Order Date

Collection Date

Symptomatic

Onset Date

First Test

Hospitalized

ICU

ODH Outbreak #

Congregate Care Patient Type: Resident Staff

Employed in Healthcare

Pregnant

ODH Facility License #

Lab

Specimen Site

Blood-Specify ( Plasma Whole )

Respiratory, Upper-Specify Below

Body Fluid-Specify Below

Nasopharyngeal (NP) swab Oropharyngeal (OP) swab Other

( CSF Other )

Respiratory, Lower-Specify Below

Serum-Specify ( Acute Conv. )

Sputum ( Induced Expectorated ) Bronchial Lavage (BAL) Trachial Aspirate (TA)

Insurance Information (if applicable)

Ordering Provider/Medical Director (if different than contact name)

Ordering Provider Phone (if different than contact phone)

NPI

Uninsured

Policy Holder Name

First

Last

Relationship to Policy Holder

Policy Holder DOB

Policy Effective Date

Name of Insurance Company

Policy Holder Social Security Number

Insurance Address

Group ID Number

City

State

Zip

Insurance ID Number (if not SSN)

Comments

Please use the Generate PDF button at the bottom of the form, then save and print the form to send with the specimen.