Communicable Form PDF Details

In order to be proactive about our health, it is important that we are familiar with the different types of communicable diseases. This week's blog post will focus on one such disease: Formiasis. Formiasis is a rare and highly contagious form of meningitis caused by the bacterium Streptococcus pneumoniae. It can be easily spread through contact with respiratory secretions, such as saliva or mucus, from an infected person. Early diagnosis and treatment is essential for preventing serious complications. In this post, we will discuss the symptoms and treatment of formiasis, as well as ways to protect yourself from infection. Stay safe and healthy!

QuestionAnswer
Form NameCommunicable Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdisease form, communicable disease form, north carolina communiable disease form editable, nc communicable form

Form Preview Example

NC Electronic Disease Surveillance System

NC EDSS EVENT ID# ____________________

North Carolina Department of Health and Human Services

Division of Public Health • Epidemiology Section

Communicable Disease Branch

Confidential Communicable Disease Report — Part 1

NAME OF DISEASE / CONDITION

ATTENTION HEALTH CARE PROVIDERS:

Please report relevant clinical findings about this disease event to the local health department.

Patient’s Last Name

First

 

 

 

 

 

Middle

 

 

Suffix

Maiden/Other

 

Alias

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Birthdate (mm/dd/yyyy)

 

 

Sex

 

 

 

 

 

Parent or Guardian (of minors)

 

 

Medical Record Number

 

 

 

 

 

 

 

 

 

 

 

M

 

F

Trans.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient’s Street Address

 

 

 

 

City

 

 

 

State

ZIP

County

 

 

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(_____) _____-_______

 

Age

 

Age Type

 

Race (check all that apply):

 

 

 

 

Ethnic Origin

Was patient hospitalized for

Did patient die from

Is the patient

 

 

 

 

 

Years

 

White

 

 

 

 

 

Asian

 

Hispanic

this disease? (>24 hours)

this disease?

pregnant?

 

 

 

 

 

Months

 

Black/African American

 

 

 

Other

 

Non-Hispanic

Yes

No

 

 

Yes

No

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

Weeks

 

American Indian/Alaska Native

Unknown

Date /

/

 

 

 

 

 

 

 

 

 

 

Days

 

Native Hawaiian or Pacific Islander

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient is associated with (check all that apply):

 

 

 

 

 

 

 

In what geographic location was the patient MOST LIKELY exposed?

 

 

 

Child Care (child, household contact,

 

 

 

Correctional Facility (inmate or worker)

In patient’s county of residence

 

 

 

 

 

 

or worker in child care)

 

 

 

Long Term Care Facility (resident or worker)

Outside county, but within NC - County: ________________________

 

 

 

School (student or worker)

 

 

 

Military (active military, dependent,

Out of state - State/Territory: _________________________________

 

 

 

College/University (student or worker)

 

 

 

or recent retiree)

 

 

 

Out of USA - Country:_______________________________________

 

 

 

Food Service (food worker)

 

 

 

Travel (outside continental United States

 

 

 

 

 

 

Unknown

 

 

 

 

 

 

 

 

 

Health Care (health care worker)

 

 

 

in last 30 days)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLINICAL INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is/was patient symptomatic for

 

 

 

 

 

If a sexually transmitted disease, give specific treatment details

 

 

 

 

 

this disease?.................................. Y

N

U

1.Date patient treated:(mm/dd/yyyy) ____________

2.Date patient treated:(mm/dd/yyyy) ____________

If yes, symptom onset date (mm/dd/yyyy):

/

 

/

 

 

 

Medication ______________________________

Medication ______________________________

SPECIFY SYMPTOMS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dosage_________________________________

Dosage_________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Duration ________________________________

Duration ________________________________

DIAGNOSTIC TESTING

Provide lab information below and fax copy of lab results and other pertinent records to local health department.

Specimen

Specimen #

Specimen

Type of Test

Test

Description (comments)

Result Date

Lab Name—City/State

 

Date

 

Source

 

Result(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

 

 

 

 

/

/

 

/

/

 

 

 

 

 

/

/

 

/

/

 

 

 

 

 

/

/

 

Reporting Physician/Practice:

____________________________________________________________

Contact Person/Title: ___________________________________________

Phone: (_____) _____–_________ Fax:(_____) _____– _______________

Health Care Provider for this disease (if not reporting physician):

____________________________________________________________

Contact Person/Title: ___________________________________________

Phone: (______) ______– ________ Fax: (______) ______– __________

LOCAL HEALTH DEPARTMENT USE ONLY

Initial Date of Report to Public Health:____/____/_______

Initial Source of Report to Public Health: Health Care Provider (specify):

Hospital

Private clinic/practice

Health Department

Correctional facility

Laboratory

Other

Is the patient part of

an outbreak of this disease?

Yes

No

Outbreak setting:

Household/Community (specify index case):______________________________

Restaurant/Retail

Assisted living facility

 

 

Child Care

Adult day care

 

 

Long term care

School

Name of facility___________________________

Healthcare setting

Prison

Address of facility_________________________

Adult care home

 

________________________________________

DHHS 2124 (Revised January 2016) EPIDEMIOLOGY

Diseases and Conditions Reportable in North Carolina

Physicians must report these diseases and conditions to the county local health department, according to the North Carolina Administrative Code: 10A NCAC 41A.0101 Reportable Diseases and Conditions (see below). Contact information for local health departments can be accessed at www.ncalhd.org/directors. If you are unable to contact your local health department, call the 24/7 pager for N.C. Communicable Disease Branch (919) 733-3419.

For diseases and conditions required to be reported within 24 hours, the initial report shall be made by telephone to the local health department, and the written disease report be made within 7 days. The reporting rules and disease report forms can be accessed at: http://epi.publichealth.nc.gov/cd/report.html

Diseases in BOLD ITALICS should be reported immediately to local health department.

Reportable to Local Health Department Within

DISEASE/CONDITION 24 Hours

A-G

ANTHRAX...............................................................................................

BOTULISM, FOODBORNE ....................................................................

BOTULISM, INTESTINAL (INFANT) ......................................................

BOTULISM, WOUND..............................................................................

Campylobacter infection..........................................................................

Chancroid ................................................................................................

Chikungunya ............................................................................................

Cholera ....................................................................................................

Cryptosporidiosis .....................................................................................

Cyclosporiasis .........................................................................................

Diphtheria ................................................................................................

E.coli infection, shiga toxin-producing .....................................................

Foodborne disease: Clostridium perfringens...........................................

Foodborne: staphylococcal......................................................................

Foodborne disease: other/unknown ........................................................

Foodborne poisoning: ciguatera..............................................................

Foodborne poisoning: mushroom............................................................

Foodborne poisoning: scombroid fish......................................................

Gonorrhea ...............................................................................................

Granuloma inguinale ...............................................................................

H-N

Haemophilus influenzae,

invasive disease ....................................................................................

Hemolytic-uremic syndrome (HUS) .........................................................

HEMORRHAGIC FEVER VIRUS

INFECTION .............................................................................................

Hepatitis A................................................................................................

Hepatitis B, acute ....................................................................................

HIV/AIDS

HIV.........................................................................................................

AIDS ......................................................................................................

Influenza virus infection causing death ....................................................

Listeriosis.................................................................................................

Measles (rubeola)....................................................................................

Meningococcal disease, invasive ............................................................

Middle East respiratory syndrome (MERS) .............................................

Monkeypox ..............................................................................................

NOVEL INFLUENZA VIRUS INFECTION...............................................

O-U

Ophthalmia neonatorum..........................................................................

Pertussis (Whooping Cough)...................................................................

PLAGUE..................................................................................................

Poliomyelitis, paralytic .............................................................................

Rabies, human ........................................................................................

Rubella ....................................................................................................

Salmonellosis ..........................................................................................

S. aureus with reduced susceptibility to vancomycin ..............................

SARS coronavirus infection ..................................................................

Shigellosis ...............................................................................................

SMALLPOX.............................................................................................

Syphilis

primary...................................................................................................

secondary..............................................................................................

early latent.............................................................................................

late latent...............................................................................................

late with clinical manifestations..............................................................

congenital ..............................................................................................

Tuberculosis ............................................................................................

TULAREMIA ...........................................................................................

Typhoid Fever, acute ...............................................................................

V-Z

Vaccinia ...................................................................................................

Vibrio infection, other than cholera & vulnificus.......................................

Vibrio vulnificus .......................................................................................

Zika..........................................................................................................

DHHS 2124 (Revised January 2016) EPIDEMIOLOGY

Reportable to Local Health Department Within

DISEASE/CONDITION 7 Days

A-G

Brucellosis ................................................................................................

Chlamydial infection—laboratory confirmed ............................................

Creutzfeldt-Jakob Disease .......................................................................

Dengue .....................................................................................................

Ehrlichiosis, HGA (human granulocytic anaplasmosis) ............................

Ehrlichiosis, HME (human monocytic or e. chaffeensis) ..........................

Ehrlichiosis, unspecified ...........................................................................

Encephalitis, arboviral, WNV ....................................................................

Encephalitis, arboviral, LAC .....................................................................

Encephalitis, arboviral, EEE .....................................................................

Encephalitis, arboviral, other ....................................................................

H-N

Hantavirus infection..................................................................................

Hepatitis B, carriage .................................................................................

Hepatitis B, perinatally acquired...............................................................

Hepatitis C, acute .....................................................................................

Legionellosis.............................................................................................

Leprosy ....................................................................................................

Leptospirosis ............................................................................................

Lyme disease ...........................................................................................

Lymphogranuloma venereum...................................................................

Malaria......................................................................................................

Meningitis, pneumococcal ........................................................................

Mumps......................................................................................................

Non-gonococcal urethritis.........................................................................

O-Z

Pelvic inflammatory disease......................................................................

Psittacosis ................................................................................................

Q fever......................................................................................................

Rocky Mountain Spotted Fever ................................................................

Rubella, congenital syndrome ..................................................................

Streptococcal infection, Group A, invasive ...............................................

Tetanus .....................................................................................................

Toxic shock syndrome, non-streptococcal................................................

Toxic shock syndrome, streptococcal.......................................................

Trichinosis ................................................................................................

Typhoid, carriage (Salmonella typhi) ........................................................

Yellow fever ..............................................................................................

You may be contacted by the local health department for additional information about this case. Medical record information relevant to the investigation and/or control of a communicable disease is exempt from the HIPAA Privacy Rule (see 45 CFR 164.512(a) ) and is permitted as an exception to confidentiality of records in NC State Law GS § 130 A-130.

North Carolina General Statute:

§130A-135. Physicians to report.

A physician licensed to practice medicine who has reason to suspect that a person about whom the physician has been consulted professionally has a

communicable disease or communicable condition declared by the : Commission to be reported, shall report information required by the Commission to the local health director of the county or district in which the physician is consulted.

North Carolina Administrative Code:

10A NCAC 41A.0101 Reportable Diseases and Conditions

(a)The following named diseases and conditions are declared to be dangerous to the public health and are hereby made reportable within the time period specified after the disease or condition is reasonably suspected to exist: