Integrated Program for the
Eradication of Poliomyelitis in Macau

Acute Flaccid Paralysis

= Case Laboratory Request Form =

Reference: Cep3AFPform

Reserved (UTVE)

DDO case No:

SOURCE OF SAMPLE
Institution: Patient/Record No:

Unit:

CEP coordinator:

PATIENT IDENTIFICATION & HISTORY
Name: Sex: Date of birth:
Guardian’s name (mother/other): Telephone:
Address (in full):
Date of last dose of polio vaccine:                                                      Type of vaccine (OPV or IPV):
 
Signs and symptoms (please specify, with date of onset):
AFP: Fever:
Other:
 

STOOL SPECIMENS (IMPORTANT: 2 specimens should be collected 24-48 hours apart)
   Stool 1 " date collected:                                      number of days after onset of paralysis:
   Stool 2 " date collected:                                      number of days after onset of paralysis:

  Date of stool specimens sent to lab  "  stool 1:                                               stool 2:

Preliminary clinical diagnosis:
 
Name of person to whom laboratory should send the results:
Complete address:

Telephone(s):                                                            ext.:                                    Fax:

FOR USE BY THE RECEIVING LABORATORY
Name of lab:                                                                                           Date received:
Name of person receiving specimen at lab:

Arrival condition of specimen*:
amount:                                      desiccation:                           container and temperature:
- obs:
 

* Criteria for "good" condition: adequate volume (>8 grams), no leakage, no desiccation, and temperature indicator or presence of ice/frozen icepacks indicating cold chain was maintained.