Patient's Name (Last) (First) (Middle Initial)
Street Address
City
State
ZIP Code
County
Reservation
Is this a student (if yes, grade__________)
Diagnosis or Suspect Reportable Condition Onset Date
3. SCHOOL REPORTER AND PROVIDER INFORMATION
School Address
City State Zip Code Telephone #
Provider Street Address City State ZIP Code Telephone #
Lab Name, Address and Telephone # (if available)
School Reporter (name of school nurse or other reporting)
Medical Provider Diagnosing (If applicable)
Diagnosis Date
5. HEPATITIS PANEL 6. TUBERCULOSIS (TB)
4. SEXUALLY TRANSMITTED DISEASES (STD) AND HIV/AIDS
Guardian
Outcome
Is the patient any of the following?
Telephone #
County / IHS Number
Date of Birth
Race
(Check all that apply)
Ethnicity Gender Pregnant
White
SCHOOL COMMUNICABLE DISEASE REPORT (CDR)
Important Instructions - Please complete Sections 1 through 4 for all reportable conditions. Once completed
return to the Pima County Health Department by faxing (520) 838-7538, or calling (520) 724-7797. This form is
also found on: http://webcms.pima.gov/health/resources_for_professionals/communicable_disease_reporting
Hispanic Male
Pacific Islander
Survived
Diagnosis Site of Infection
Hepatitis A Serology Results
Site of Disease
School name
Provider's Facility/Clinic/Hospital
Medicine and Dosage
(Please enter information)
TB Infection in a Child
5 and Under
(Positive
TB skin test result)
Hepatitis B Serology Results
Hepatitis A Antibody (Acute IgM anti-HAV)
Pulmonary
Hepatitis B surface Antigen (HBsAg)
Hepatitis B core Antibody IgM (HBcAb-IgM)
Hepatitis B core Antibody Total (HBcAb)
Hepatitis B surface Antibody (HBsAb)
Hepatitis B e Antigen (HBeAg)
Symptoms consistent with acute hepatitis
Jaundice
Pos
Laryngeal
Extrapulmonary
Pos
Neg
Neg
Unk
Unk
Hepatitis C Serology Results
Hepatitis C-RIBA
Hepatitis C-NAT/PCR
Hepatitis C-Viral Load
Patient had Sexual
Marital Status
Date Drug Dosage
Dosage
Dosage
Drug
Drug
Date
Date
Comments
Health care worker
Facility Name
Date
Food worker/handler
& Address
Childcare worker/attendee
Native American
Non-Hispanic
Female
No
Yes
State ID / MEDSIS ID
1. PATIENT INFORMATION
2. REPORTABLE CONDITION INFORMATION
L
A
B
R
E
S
U
L
T
S
Date Received by County
Black
Asian
Unknown
Other
Unknown
Unknown
Due Date
Syphilis (specify below)
Chlamydia
HIV/AIDS
Primary
Gonorrhea
Risk Factors
Secondary
PID
Early Latent (<1 year) Sex with IDU
Genitalia
Males Only
Females Only
Both
Refused
Unknown
Married
Single
Divorced
Widowed
Separated
Domestic
Partner
Unknown
Throat
Rectum
Other
Late (>1 year)
Herpes
Sex Partners
Congenital
Mother's Name Mother's DOB
Chancroid
# of partners
# of partners treated
Other Syphilis
Neurological Symptoms
IDU
Liver Function Test
ALT
AST
Liver Function Test
ALT AST
Contact with
Specimen Type
Blood CSF Urine
Stool
NP Swab
Sputum
Other
Lab Result
Date Collected
Date Finalized
Lab Test
Specimen Type
Blood CSF Urine
Stool
NP Swab
Sputum
Other
Lab Result
Date Collected
Date Finalized
Lab Test
PID
Died
Unknown
Version 06/02/2008
Treatment
Hepatitis C-EIA s/co ratio
UnkNegPos
Date of Last
Negative HIV
Test
Sex with males
Print Form
Is this a staff (if yes, occupation________________________)
