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First Name
Last Name
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Today’s Date (mm/dd/yyyy)
Name
Phone Number
Email Address
Complaint Information:
What is the nature of your complaint?
What is the location of the area of concern (be as specific as possible)?
What is the date(s) and time(s) you observed the condition or action of concern?
Any Additional Details
Disease Reported
Patients Last Name
Patients First Name
Middle Name (or initial and/or suffix)
Address (number and street)
County
City
State
Zip
Patient Expired YesNoUnknown Home Phone Number Work Phone Number Alternative Phone Number Date of Birth
Age
Sex MaleFemale
Pregnant YesNoUnknown
Due Date
Race (Check All That Apply) American Indian or Alaskan NativeAsianAfrican AmericanNative Hawaiian or Pacific IslanderWhiteOtherUnknown
Ethnicity (Check One) HispanicNon-HispanicUnknown
Was patient contacted? YesNoUnknown
Sensitive occupation? (Check all that apply)Food handlerChild care attendee/staffLong-term care resident/staffDirect patient careNot applicable
Name of Facility
Address of Facility
Parent, guardian, or alternate contact name
Phone
Healthcare provider name
Healthcare provider phone number
Healthcare provider address
Healthcare facility name
Healthcare facility phone number
Healthcare facility address
Submitted by (contact name, facility)
Submitted by phone number
Date of report
Date of onest
Date of diagnosis
Hospital admission
Hospital discharge
Date of death
Status Laboratory confirmedClinically diagnosed (list symptoms)
List symptoms if "clinically diagnosed" was selected:
Date of result
Laboratory name
Laboratory phone number
Laboratory address
Date of specimen collection
Reason for test DxPrenatalRepeat pos
Specific type of test (e.g. smear, culture, ELISA)
Specimen site/type BloodStoolCSFUrineCervixUrethraSputumOther
If "other" was selected please explain:
Treatment TreatedUntreated
If "untreated" selected please select the reason: Will treatUnable to contactRefused treatmentReferred to:
If "referred to" was selected please provide provider:
Date treatment initiated
Detail drugs/dose/route
Remarks
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