meningococcal reference unit request form€¦ · mru. hays dx: meningococcal reference unit . phe...
TRANSCRIPT
MENINGOCOCCAL REFERENCE UNIT REQUEST FORM
DET
AIL
S O
F SE
ND
ER LABORATORY (Clearly state department, please):
ADDRESS: Tel: Fax: Out of hours contact no: NAME OF CCDC / HEALTH PROTECTION CONSULTANT FOR DISTRICT OF PATIENT’S RESIDENCE: ADDRESS: Tel: Fax: Out of hours contact no:
PATI
ENT
DET
AIL
S
SURNAME* : CONSULTANT:
FORENAME* : WARD:
DOB* : HOSPITAL:
SEX: male / female
NHS NUMBER* HOSPITAL NUMBER:
HOME ADDRESS:
HOME POST CODE* *Essential information
CLI
NIC
AL
INFO
RM
ATI
ON
DATE OF ONSET: FATAL: yes / no / nk
CLINICAL DETAILS PATIENT STATUS: case / carrier / contact
RECENT TRAVEL ABROAD: yes / no / nk
COUNTRY:
TYPE OF INCIDENT: sporadic / outbreak
ANTIBIOTIC TREATMENT: CONTACT HISTORY: family / school / none / nk
Further information (associated cases, transfers from other hosptials etc): Details of ALL isolates of N. meningitidis: CSF, Blood, Throat, Joint, Other
Meningococcal Vaccination History Plain polysaccharide: A, C, Y, W Conjugated polysaccharide: A , C, Y, W Protein-based vaccine (eg. Bexsero®) Other
SPEC
IMEN
DET
AIL
S
Test required Specimen Clinical Site Please send all meningococci
isolated stating site/s
Senders Reference Date of collection MRU use only
N. meningitidis
Identification, typing & antibiotic susceptibility (MIC) testing
1.
2.
3.
PCR
Meningococcal PCR □ Pneumococcal PCR □
EDTA / Plasma
CSF
Serum (clotted blood)
Other / Joint Fluid
For Meningococcal Serology use the Vaccine Preventable Serology (PHE Vaccine Evaluation Unit) request form, available via
MMMP on the MFT website www.cmft.nhs.uk/mmmp/VEUrequestform.
PLEASE COMPLETE FULLY TO AVOID DELAYS
Public Health England Meningococcal Reference Unit Manchester Medical Microbiology Partnership (MMMP) Clinical Sciences Building 2, Manchester Royal Infirmary, Oxford Road, Manchester. UK M13 9WL Tel: +44 (0)161 276 6757 Fax: +44(0)161 276 5744
For request forms see PHE M
RU website https://w
ww
.gov.uk/government/collections/m
eningococcal-reference-unit-mru
Hays DX: Meningococcal Reference Unit PHE North West, Manchester Lab DX 6962410 Manchester 90 M
MMMP-QU-FORM24 Version: 8 Active Date: 5th December 2017 Author: Dr. S. Gray