Streptococcus pneumoniae Testing Request Form

Contact Information:

Name*
Phone Number*
Email Address*
Affiliation* (e.g., state health department, nursing home, etc. with which you are affiliated)

Impact:

How will serotyping 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, gender, 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 vaccinationhistory* (please differentiate between Prevnar-7 and Prevnar-13)
Underlying condition(s) present* Yes     No
If yes, please specify
Any other pertinent information

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