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