Streptococcus pneumoniae Testing Request Form

Contact Information:

Name*

Phone Number*

Email Address*

Affiliation* (e.g., state health department, skilled nursing facility, etc. with which you are affiliated)

Impact:

How will isolate testing influence clinical management or public health action?*

Case(s) Description (enter 'N/A' if information unavailable):

Antibiotic susceptibility results (please include all tests and results)*


Epidemiologic information (patient's age group, culture date, epidemiologic link between multiple cases, etc.)*


Sterile site from which isolate(s) was obtained (for examples of sterile sites, see the ABCs Case Definition page)*
Blood cerebrospinal fluid (CSF) pleural fluid peritoneal fluid pericardial fluid surgical aspirate bone joint fluid internal body site (e.g., lymph node, brain) other N/A

Pneumococcal vaccination history* (please differentiate between pneumococcal conjugate vaccines (PCV))

Underlying condition(s) or risk factors present*
Yes     No
If yes, please specify

Any other pertinent information


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