COMMUNICABLE DISEASE REPORT
Important Instructions: Please complete sections 1-3 for all reportable conditions. In addition, complete
Section 4 for STDs and HIV/AIDS cases, Section 5 for hepatitis, and Section 6 for tuberculosis. Once
completed, return to your county or tribal health agency. If reporting through MEDSIS, go to siren.az.gov
.
County / IHS Number
State ID /
MEDSIS ID
Date Recived by County
1. PATIENT INFORMATION
Patient’s Name (Last, First, Middle)
Date o
f
Birth
Race (check all that apply):
White Pacific Islander Unknown
Black Native American
Asian Other
Ethnicity:
Hispanic
Non-Hispanic
Unknown
Gender:
Male Unknown
Female Transgende
Pregnant:
No Unknown
Yes
Due date
Street Address:
City:
State:
Zip code:
County:
Reservation:
T
elephone#:
Patient’s Occupation or School:
Guar
dian:
(not necessary for STD)
Ou
tcome:
Survived
Died Date:
Is the patient any of the following?
Healthcare worker Food worker/handler School or childcare worker or attendee
Facility Name & Address:
2. REPORTABLE CONDITION INFORMATION / LAB RESULTS 3. REPORTER & PROVIDER INFORMATION
Diagnosis or Suspect Reportable Condition
Onset Date
Diagnosis Date
Date
Collected
Date
Finalized
Specimen T
ype
Blood CSF Urine
Stool NP Swab Sputum
Other
Lab Test
Lab Result
Date
Collected
Date
Finalized
Specimen Type
Blood CSF Urine
Stool NP Swab Sputum
Other
Lab Test
Lab Result
L
A
B
R
E
S
U
L
T
S
Date
Collected
Date
Finalized
Specimen Type
Blood CSF Urine
Stool NP Swab Sputum
Other
Lab Test
Lab Result
Reporting Source (Physician or other reporting source)
F
acility
Street Address City State
Zip code
Telephone#
Provider (if different from Reporter)
F
acility
Provider Street Address
Cit
y
State
Zip code
Telephone#
Laboratory Name, Address and Telephone#
4. SEXUALLY TRANSMITTED DISEASES (STD) AND HIV/AIDS 5. HEPATITIS PANEL 6. TUBERCULOSIS (TB)
Diagnosis
Syphilis (specify below)
Primary
Secondary
Early Latent (<1 year)
Late (> 1 year)
Congenital
Mother’s Name:
Mother’s DOB:
Other Syphilis
Neurological symptoms:
Chlamydia
PID
Gonorrhea
PID
Herpes
Chancroid
HIV/AIDS
Risk Factors
IDU
Sex with IDU
Sex with
males
Date of Last
Negative HIV
Test:
Site of Infection
Genitalia Rectum
Throat Other
Patient had Sexual Contact with:
Males only Refused
Females only Unknown
Both
Marital Status
Married Single
Divorced Widowed
Separated Domestic
Unknown
partner
Sex Partners:
# Sex partners
# Sex partners treated
Treatment
Date Drug Dosage
Date Drug Dosage
Date Drug Dosage
Hepatitis A Serology Results
Hepatitis A Antibody (acute IgM anti-HAV)
Pos Neg Unk
Hepatitis B Serology Results
Hepatitis B surface Antigen (HBsAg)
Pos Neg Unk
Hepatitis B core Antibody IgM (HBcAb-IgM)
Pos Neg Unk
Hepatitis B core Antibody Total (HBcAb)
Pos Neg Unk
Hepatitis B surface Antibody (HBsAb)
Pos Neg Unk
Hepatitis B e Antigen (HBeAg)
Pos Neg Unk
Symptoms consistent with acute hepatitis
Yes No Unk
Jaundice
Yes No Unk
Liver Function Test ALT:
AST:
Hepatitis C Serology Results
Hepatitis C-EIA Pos Neg Unk s/co ratio:
Hepatitis C-RIBA
Pos Neg Unk
Hepatitis C-NAT/PCR
Pos Neg Unk
Hepatitis C-Viral Load
Liver Function Test
ALT:
AST:
Site of Disease
Pulmonary
Laryngeal
Extrapulmonary
TB Infection in a
Child 5 and Under
(Positive TB skin test
result)
Medicine and Dosage
ADHS 4/11/2008
Version: 06-2009 This form is located online at: http://www.azdhs.gov/phs/oids/epi/pdf/cdr_form.pdf
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