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