State of Nevada
Confidential Morbidity Report Form
Updated December 2019
Attending Physician
Provider
Person Reporting / Job Title
Facility Name
Physician Phone
Reporter Phone
Facility Phone
Physician Fax
Reporter Fax
Report Date
Address
Name
City State Zip
County
Parent or Guardian Name
Occupation / Employer / School
Pregnancy EDC
Social Security Number Medical Record Number
Birth Country and Arrival Date Marital Status
Race
Ethnicity
Primary Language Spoken
Single
Married
Widowed
Separated
Divorced
Unknown
White
Black
Asian
American Indian
Pacific Islander
Other
Hispanic
Non-Hispanic
Gender Female
Male
Pregnant No
Yes
Incarcerated No
Yes
Patient
Disease
Disease or Condition Name
Onset Date Diagnosis Date
Admission Date
Discharge Date Date of Death
Deceased No
Yes
Was the patient treated? No
Yes
If yes, provide the treatment details (drug name, dosage, duration, dates etc.)
Was laboratory testing ordered? No
Yes
If yes, attach the results or provide the laboratory name if the results are unavailable
Symptoms
.Comments
Fax Completed
Forms To:
Carson City: (775) 887-2138
Clark County: (702) 759-1414
Rest of State: (775) 684-5999
Date of Birth / Age
Home Phone
Sex assigned
at birth
Female
Male
Nonbinary
Clark County STD: (702) 759-1454
Washoe County: (775) 328-3764
Carson City Health & Human Services
900 E. Long St.
Carson City, NV 89706
http://gethealthycarsoncity.org
Phone: (775) 887-2190
After-Hours Phone: (775) 887-2190
Confidential Fax (775) 887-2138
Nevada Division of Public and Behavioral
Health
4150 Technology Way
Carson City, Nevada 89706
http://health.nv.gov
Phone: (775) 684-5911 (24 Hours)
Confidential Fax: (775) 684-5999
Southern Nevada Health District
PO Box 3902
Las Vegas, NV 89127
http://www.snhd.info
Confidential Fax: (702) 759-1414
Epidemiology
Phone: (702) 759-1300 (24 hours)
Confidential Fax: (702) 759-1414
STDs, HIV, and AIDS
Phone: (702) 759-0727
Confidential Fax: (702) 759-1454
Tuberculosis
Phone: (702) 759-1015
Confidential Fax: (702) 759-1435
1001 E. Ninth St., Building B
P. O. Box 11130
Reno, Nevada 89520-0027
http://www.washoecounty.us/health/
Phone: (775) 328-2447 (24 hours)
Confidential Fax: (775) 328-3764
Completed reports can be faxed to the
numbers listed on the front of this form.
Diseases requiring immediate
investigation and/or prophylaxis (e.g.,
invasive meningococcal disease, plague)
should be also reported by telephone to
the appropriate health jurisdiction.
Nevada Reportable Diseases
Provider Information
Attending Physician/Phone/Fax
The physician primarily responsible for
the care of this patient
Person Reporting/Phone/Fax
Provide if different than attending
physician
Facility Name/Phone
List the location for facilities with
multiple locations.
Report Date
The date that this report is submitted
Patient Information
Sufficient information must be provided to
allow the patient to be contacted. If insuffi-
cient information is provided, you will be
contacted to provide that information.
Attaching a patient face sheet to this
report is an acceptable method of provid-
ing the patient demographic information.
Address/County/City/State/Zip
The home address of the patient,
including the county
Date of Birth / Age
The patient’s date of birth or age if
birthdate is unknown.
Parent or Guardian Name
For patients under the age of 18, the
name of the person(s) responsible for
the patient
Phone
The home phone of the patient
Occupation / Employer / School
The occupation or employer of the
patient, or the name of the school
attended for students
Social Security Number
This information greatly assists in the
investigation of cases, allowing easier
access to laboratory and medical
records.
Medical Record Number
A patient identifier unique to the facility
or office
Gender /
Sex Assigned at Birth
The current gender of the patient
and the sex assigned at birth
Pregnant / Pregnancy EDC
The pregnancy status of the patient
and their estimated date of
confinement (projected delivery date)
Marital Status
The marital status of the patient
Race / Ethnicity
Race and ethnicity categories have
been chosen to match those used by
The Nevada Administrative Code Chapter 441A requires reports of specified diseases, foodborne illness outbreaks and extraordinary
occurrences of illness be made to the local Health Authority. The purpose of disease reporting is to recognize trends in diseases of
public health importance and to intervene in outbreak or epidemic situations. Physicians, veterinarians, dentists, chiropractors, regis-
tered nurses, directors of medical facilities, medical laboratories, blood banks, school authorities, college administrators, directors of
child care facilities, nursing homes and correctional institutions are required to report. Failure to report is a misdemeanor and may be
subject to an administrative fine of $1,000 for each violation.
the Centers for Disease Control and
Prevention
Primary Language Spoken
Providing this information makes it
easier to contact non-English-speaking
patients and arrange for translators
Birth Country and Arrival Date
If the patient was not born in the United
States, provide the patient’s country of
origin and date of arrival in the US.
Incarcerated
The incarceration status of the patient.
If the patient is currently incarcerated,
list the facility in the comments section
Disease Information
Disease or Condition Name
This form should be used for all legally
reportable diseases in the state of
Nevada
Onset Date
The date of the first symptom
experienced by the patient
Diagnosis Date
The date that this disease was
diagnosed. For reports of suspect
illness, enter the date the illness
was suspected.
Date Admitted/Discharged
For any patients admitted to a hospital,
the date of admission and discharge (if
the patient has been discharged)
Deceased / Date of Death
If the patient has died, list the date of
death. If known, list the cause of death
under comments.
Symptoms
All relevant symptoms
Laboratory Testing
If laboratory testing has been ordered,
please attach the laboratory results to
this form. If relevant tests are pending,
list them in the comments section, as
well as the name of the laboratory
performing the testing
Treatment
Treatment information is necessary
for the reporting of sexually-
transmitted diseases, and helpful in
the investigation of other illnesses. If
this field is left blank, you will be
contacted to provide this information
Comments
Provide any additional information that
may be useful in the investigation or to
explain answers given elsewhere on
this form
HIPAA and Public Health Reporting
HIPAA laws were developed so as not to interfere with the ability of local public health authorities to collect information. According to
45 CFR 160.204(b): “Nothing in this part shall be construed to invalidate or limit the authority, power, or procedures established under
any law providing for the reporting of disease or injury, child abuse, birth, or death, public health surveillance, or public health investiga-
tion or intervention.”
How To Report
Instructions for Completing the Morbidity Report Form
Contact Information
State of Nevada
Confidential Morbidity Report Form Instructions
Updated Dec 2019
AIDS
Amebiasis
Animal bite from a
rabies-
susceptible
species*
Anthrax
Arsenic:
Exposures and
Elevated Levels
Botulism*
Brucellosis
Campylobacteriosis
CD4 lymphocyte
counts <500/μL
Chancroid
Chlamydia
Cholera
Coccidioidomycosis
Cryptosporidiosis
Diphtheria
Drowning
Drug-Resistant
Streptococcus
pneumoniae
Invasive
Disease
Ehrilichosis/
anaplasmosis
E. coli 0157:H7
Encephalitis
Exposures of Large
Groups of
People
Extraordinary
occurrence of
illness (e.g.
Smallpox,
Dengue,
SARS)*
Giardiasis
Gonorrhea
Granuloma inguinale
Group A
Streptococcal
Invasive
Disease
Haemophilus
influenzae
(invasive)
Hansen’s Disease
(leprosy)
Hantavirus
Hemolytic-uremic
syndrome (HUS)
Hepatitis A, B, C,
delta, unspecified
HIV infection
Influenza
Lead:
Exposures
and Elevated
Levels
Legionellosis
Leptospirosis
Listeriosis
Lyme Disease
Lymphogranuloma
venereum
Malaria
Measles (rubeola)
Meningitis (specify
type)
Meningococcal
Disease*
Mercury:
Exposures and
Elevated Levels
Mumps
Outbreaks of
Communicable
Disease*
Outbreaks of
Foodborne
Disease*
Pertussis
Plague*
Poliomyelitis
Psittacosis
Q Fever
Rabies (human or
animal)*
Relapsing Fever
Respiratory Syncyti-
al Virus (RSV)
Rotavirus
Rubella (including
congenital)
Salmonellosis
Severe Reaction to
Immunization
Shigellosis
Syphilis (including
congenital)
Tetanus
Toxic Shock
Syndrome
Trichinosis
Tuberculosis
Tularemia
Typhoid Fever
Vancomycin-
intermediate
Staphylococcus
aureus (VISA)
and Vancomycin-
resistant
Staphylococcus
aureus (VRSA)
Infection
Vibriosis, Non-
Cholera
Viral Hemorragic
Fever
West Nile Virus
Yellow Fever
Yersiniosis
* Must be reported immediately
Must be reported when suspect
Reportable in Clark County Only
All cases, suspect cases, and carriers
ust be reported within 24 hours
Disease Reporting
Washoe County Health District
Animal Control Contact Information
Spotted Fever
Rickettsioses
Click Link for Contact Sheet
After Hours Duty Officer: (775) 400-0333
Latent Tuberculosis
<5 years age
m