Table shows Form used in laboratories to be submitted with sample.

Table 2: Table shows Form used in laboratories to be submitted with sample.

Submitter Information
Name of submitting hospital, laboratory or other facility
Physician
Address
Phone number
Case definition	O Suspected O Probable case
Patients Information
First Name	Last Name
Patients ID number	DOB:	Age:
Address	Sex:	Phone number:
Specimen Information
Type of Specimen	O Nasopharyngeal and oropharyngeal swab O Bronchoalveolar lavage O Endotracheal aspirate O Nasopharyngeal aspirate O Nasal wash O Sputum O Sputum O Serum O lung tissue O Whole blood O Stool
Please tick the box if sample taken is postmortem
Clinical details
Date of symptom onset
Has patient has history of travelling to affected area	O Yes O No	O Country: O Return date:
Has the patient had contact with confirmed cases?	O Yes O No	O Unknown O Other exposure
Additional information