Connecticut Uc 2 Form PDF Details

In the realm of public health and preventive medicine, precise and timely reporting of certain diseases is paramount. This necessity gives rise to various forms and reporting mechanisms, such as the Connecticut Uc 2 Form. Despite its association with the Houston Department of Health and Human Services, this form serves as a pivotal tool in the systematic collection of data regarding sexually transmitted diseases (STDs). It encompasses a wide array of sections ranging from patient demographic data, disease data, laboratory data, to treatment information, ensuring comprehensive reporting. Facilities and clinics are required to complete this form when reporting instances of reportable diseases like syphilis, gonorrhea, chlamydia, and chancroid, as well as voluntary disease reports which include genital herpes, genital warts, among others. The form not only captures detailed patient information such as name, date of birth, contact information, marital, and pregnancy status but also delves into the specifics of the disease being reported, the diagnostic tests conducted, and treatments administered. Moreover, it emphasizes the confidentially managed surveillance by the Bureau of Epidemiology – STD Surveillance, reflecting the sensitive nature of the information handled and the rigorous efforts to maintain patient privacy while accruing essential data to combat the spread of STDs. This balance of detailed reporting with confidentiality underscores the form's critical role in public health initiatives focusing on STD prevention and control.

QuestionAnswer
Form NameConnecticut Uc 2 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesuc ct form online, connecticut uc, uc 2 form ct, ct employer contribution return

Form Preview Example

CONFIDENTIAL STD MORBIDITY REPORT FORM

Houston Department of Health and Human Services

ATTN: Bureau of Epidemiology – STD Surveillance 4th floor

8000 North Stadium Drive Houston, Texas 77054

Tel: (832)393-5080 Fax: (832)393-5233

 

 

Reported by:

 

Facility/Clinic:

 

Phone Number:

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PATIENT DEMOGRAPHIC DATA

 

 

 

 

 

 

 

Last Name

 

 

 

 

 

First Name, MI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DOB

 

 

 

 

 

Social Security #

 

 

 

Sex

 

 

Race

 

 

 

 

 

Hispanic

 

 

 

 

 

 

 

 

 

 

 

 

 

Y

 

N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

Home Phone

(

)

--

 

 

 

 

 

City, State Zipcode

 

 

 

 

 

Other Phone

(

)

--

 

 

 

 

 

Emergency Contact Name

 

 

 

 

 

Contact Phone

(

)

--

 

 

 

 

 

Marital Status

Single

Married

Divorced

Widowed

Unknown

 

 

 

 

 

 

 

Pregnancy Status

N/A

No

Yes (Expected delivery date___/___/___)

 

Unknown (Last menstrual date___/___/___)

 

 

Reason for Test (STD related, prenatal;, immigration, etc):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DISEASE DATA

 

 

 

 

 

 

 

 

 

 

Check Reportable Disease(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Syphilis

 

 

Gonorrhea

 

Chlamydia

 

 

Chancroid

 

 

 

List Signs and Symptoms:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check Voluntary Disease(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Genital Herpes

 

Genital Warts

 

 

Non-specific Urethritis

 

Pelvic Inflammatory Disease

 

 

 

Trichomoniasis

 

Other non-specific Vaginitis

Mucopurulent Cervicitis

 

Other _________________

 

LABORATORY DATA

Date of Collection/Test

Diagnostic Test

Results

Laboratory

TREATMENT INFORMATION

Prior History of Treatment Yes No

Unknown

Date of Previous Treatment _____/_____/_____

 

 

 

 

Method of Prior Treatment_________________

 

 

CURRENT TREATMENT INFORMATION:

 

 

 

 

Date (s) of Treatment

Method of Treatment / Dose

Provider

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Notes/Comments/Patient History/Risk Factors:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

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