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Name: __________________________________________ Date: _____________ Score: _____________
Procedure 3–1 Steps
Start Time: End Time: Total Time:
1. Locate and open the patient’s chart (paper or electronic). 10
2. Log on to the local public health services website and
locate the Disease Reporting link.
3. Locate the information in the patient’s chart to be
reported (e.g., tuberculosis).
4. Following the instructions on the form, accurately
complete the confidential report.
5. Following the reporting criteria, telephone and/or
electronically (including fax) report the disease as
6. Demonstrating sensitivity to patient rights, contact the
receiving party by telephone to confirm the correct fax
number and that the recipient is available to receive PHI.
Protect the integrity of the medical record.
7. Fax a copy of the document (with fax cover sheet) to the
public health department.
8. Remove the fax document(s) and place (or scan) in the
Points Awarded / Points Possible _____/