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 vaccination history* (please differentiate between Prevnar-7 and Prevnar-13)

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

Any other pertinent information


Security Question:*
To prevent spam, please solve this simple math problem below:
12-6 =