Dhhs 2124 Form – Fill Out and Use This PDF

NC 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 is associated with (check all that apply):

In what geographic location was the patient MOST LIKELY exposed?

In patient’s county of residence

Child Care (child, household contact, or worker in child care)

School (student or worker) College/University (student or worker) Food Service (food worker)

Health Care (health care worker) Migrant Worker Camp

Correctional Facility (inmate or worker) Long Term Care Facility

(resident or worker) Military (active military, dependent, or recent retiree) Travel (outside continental United States in last 30 days) Other

Outside county, but within NC - County: Out of state - State/Territory:

Out of USA - Country: Unknown

Is/was patient symptomatic for this disease?

Yes

No

Unknown

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

/ /

SPECIFY SYMPTOMS:

If a sexually transmitted disease, give specific treatment details
1. Date patient treated:(mm/dd/yyyy)	/	/	2. Date patient treated:(mm/dd/yyyy)	/	/
Medication:			Medication:
Dosage:			Dosage:
Duration:			Duration:

Acquired immune deficiency syndrome (AIDS) – 24 hours Acute flaccid myelitis – 7 days

Anaplasmosis – 7 days Anthrax – immediately

Arboviral infection, neuroinvasive (WNV, LAC, EEE, other, unspecified) – 7 days Babesiosis – 7 days

Botulism – immediately Brucellosis – 7 days Campylobacter infection – 24 hours Candida auris – 24 hours

Carbapenem-Resistant Enterobacteriaceae (CRE) – 24 hours Chancroid – 24 hours

Chikungunya virus infection – 24 hours

Chlamydial infection (laboratory confirmed) – 7 days Cholera – 24 hours

COVID-19: see Novel coronavirus Creutzfeldt-Jakob disease – 7 days Cryptosporidiosis – 24 hours Cyclosporiasis – 24 hours Dengue – 7 days

Diphtheria – 24 hours

Escherichia coli, shiga toxin-producing infection – 24 hours Ehrlichiosis – 7 days

Foodborne disease, including Clostridium perfringens, staphylococcal, Bacillus cereus, and other and unknown causes – 24 hours

Gonorrhea – 24 hours Granuloma inguinale – 24 hours

Haemophilus influenzae, invasive disease – 24 hours Hantavirus infection – 7 days

Hemolytic-uremic syndrome (HUS) – 24 hours Hemorrhagic fever virus infection – immediately Hepatitis A – 24 hours

Hepatitis B – 24 hours

Hepatitis B carriage or perinatally acquired – 7 days Hepatitis C, acute – 7 days

Human immunodeficiency virus (HIV) infection confirmed – 24 hours Influenza virus infection causing death – 24 hours Interferon-gamma release assay (IGRA), all results – 7 days Legionellosis – 7 days

Leprosy – 7 days Leptospirosis – 7 days Listeriosis – 24 hours Lyme disease – 7 days Lymphogranuloma venereum – 7 days

Malaria – 7 days

Measles (rubeola) – immediately Meningitis, pneumococcal – 7 days Meningococcal disease, invasive – 24 hours

Middle East respiratory syndrome (MERS) – 24 hours Monkeypox – 24 hours

Mumps – 7 days

Nongonococcal urethritis – 7 days

Novel coronavirus infection causing death – 24 hours Novel coronavirus infection – immediately

Novel influenza virus infection – immediately Ophthalmia neonatorum – 24 hours Plague – immediately

Paralytic poliomyelitis – 24 hours Pelvic inflammatory disease – 7 days Pertussis (whooping cough) – 24 hours Psittacosis – 7 days

Q fever – 7 days

Rabies, human – 24 hours Rubella – 24 hours

Rubella congenital syndrome – 7 days Salmonellosis – 24 hours

Severe acute respiratory syndrome (SARS) – 24 hours Shigellosis – 24 hours

Smallpox – immediately

Spotted fever rickettsiosis (including RMSF)– 7 days

Staphylococcus aureus with reduced susceptibility to vancomycin – 24 hours Streptococcal infection, Group A, invasive disease – 7 days

Syphilis, primary, secondary, early latent, late latent, late with clinical manifestations, congenital – 24 hours

Tetanus – 7 days

Toxic shock syndrome, non-streptococcal or streptococcal – 7 days Trichinosis – 7 day

Tuberculosis – 24 hours Tularemia – immediately

Typhoid fever, acute (Salmonella typhi) – 24 hours Typhoid carriage (Salmonella typhi) – 7 days Typhus, epidemic (louse-borne) – 7 days Vaccinia – 24 hours;

Varicella (chickenpox) – 24 hours

Vibrio infection (other than cholera & vulnificus) – 24 hours Vibrio vulnificus – 24 hours

Yellow fever – 7 days Zika virus – 24 hours