First names

Surname

Sex (M/F)

Citizenship

ID number

Passport number (if applicable)

Other ID number (if applicable)

Date of birth

Age

Hospital number (if applicable)

Ward name (if hospitalised)

Residential address

Telephone number

Specimen type

Date of specimen collection

Date of specimen receipt into laboratory

Laboratory test performed

Pathogens isolated

1.

2.

3.

4.

Final laboratory test result

Date final result authorised and reported to health care provider

Health care provider name

Health care provider practice number

Health care provider contact number

Health establishment name

Health establishment registration number

Sub-district

District/Municipality

Province

Health establishment contact number

Laboratory name

Laboratory practice number

Pathologist or laboratory personnel name

Laboratory contact number