Test Request Form Please provide…

                                      Test Request Form
Please provide the following information for all samples submitted to the NPDPSC. Please note
that it is very important that you complete the entire form to aid the NPDPSC in providing an
accurate diagnosis. For more information on why we require this data, please see our website
(http://www.cjdsurveillance.com).

1. Drawing/Sending Laboratory

Your name:                                     Phone:                    Fax:

Laboratory/Hospital:

Street address:

City/State/Zip code:

2. Samples enclosed. (Please check all that apply.)
      CSF (Please note that we request urine be sent with all CSF samples, if available.)
      Urine (Urine will only be stored for future research purposes.)
      Fixed brain biopsy tissue (Range of formic acid should be between 88-98%)
               Treated in _____% formic acid for 1 hour.
                Sampled (If sampled, follow formic acid treatment with at least 30 minutes in
             10% formalin rinse)
      Frozen brain biopsy tissue
               Stored at:     70°C (recommended)         20°C     Refrigerator 4°C
      Fixed brain autopsy tissue (Range of formic acid should be between 88-98%)
               Treated in _____% formic acid for 1 hour.
      Frozen brain autopsy tissue
               Stored at:     70°C (recommended)         20°C     Refrigerator 4°C
      Blood (Please see our blood protocol for special instructions before sending blood.)

3. Is additional tissue available on this patient?
       No
       Yes ­ Please describe.


4. To whom should test results be submitted? (Please check all that apply.)
      Drawing laboratory                                 Referring physician




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5. Referring Physician

Name:

Telephone:                                          Fax:

Hospital/Institution:

Street address:

City/State/Zip code:

6. For all samples sent to the NPDPSC, we REQUIRE that a full clinical history be submitted to
   aid us in making our diagnosis. Has a clinical history been submitted?
       Yes, it is enclosed in this package
       Yes, it has been submitted previously
       No, it will be sent under separate cover

7. Patient Information

Name:                                                               ID#

Date of birth:                               Sex            Race

Onset (month/year):                          Date of death (if applicable):

City and state of residence:

City and state of death (if applicable):

8. Does the patient have any military experience?
      Yes                                                  No
9. Does the patient have a history of any of the following?
      Herpes encephalitis                                   Cerebral infarction
      Other viral encephalitis                              Acute brain trauma
      None of the above
10. Does the patient have any family history of CJD or early onset dementia?
       Yes, CJD                                             No
       Yes, early onset dementia
11. Does the patient have a known history of foreign travel or eating wild game?
       Yes, foreign travel: Where?
       Yes, patient ate wild game or was a hunter
       No, patient did not engage in either of these activities
12. Did the patient donate blood?
       Yes ­ In what year and city:
       No


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