Form Epid 200 PDF Details

In navigating the complex terrain of public health management, particularly in the context of infectious disease control, the Epid 200 form serves as a crucial instrument for professionals within the Kentucky Department for Public Health. Revised in June 2010, this form embodies a comprehensive data collection tool used to report various contagious illnesses that may pose significant health risks to the community. The form meticulously gathers demographic data of the patient, including name, date of birth, contact information, and ethnic origin, providing a clear patient snapshot. It further delves into the specifics of the disease in question—naming the disease, pinpointing the onset and diagnosis dates, listing symptoms, and capturing hospitalization details if applicable. For diseases transmitted through sexual contact, the form expands to encompass additional information pertinent to case detection, disease stage, and treatment rendered. Crucially, the EPID 200 form operates within a regulatory framework established by Kentucky state law 902 KAR 2:020, mandating health professionals to promptly report a delineated list of diseases to local health departments or directly to the Kentucky Department for Public Health. This regulation underscores the urgency of reporting certain diseases, ranging from those requiring immediate telephone notification, such as outbreaks indicative of a newly recognized infectious agent or bioterrorism acts, to others necessitating reportage within specified time frames. The structured yet detailed format of the EPID 200 form underscores Kentucky's proactive stance in disease surveillance and control, ensuring timely and organized reporting that is vital for initiating appropriate public health responses.

QuestionAnswer
Form NameForm Epid 200
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesKAR, kentucky reportable disease form 2020, Neuroinvasive, kentucky reportable disease form

Form Preview Example

EPID 200 (Rev Jun 2010)

Kentucky Reportable Disease Form

Department for Public Health

Division of Epidemiology and Health Planning

275 East Main St., Mailstop HS2E-A

Frankfort, KY 40621-0001

Disease Name_____________________

Mail Form to Local Health Department

DEMOGRAPHIC DATA

Patient’s Last Name

First

M.I.

Date of Birth

 

Age

 

Gender

 

 

 

 

/

/

 

 

M

F

Unk

 

 

 

 

 

 

 

 

Address

City

State

 

 

Zip

County of Residence

 

 

 

 

 

 

 

 

 

 

Phone Number

Patient ID Number

Ethnic Origin

His. Non-His.

Race

W

B

A/PI

Am.Ind.

Other

DISEASE INFORMATION

Disease/Organism

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Onset

 

 

Date of Diagnosis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

 

/

 

 

 

/

/

List Symptoms/Comments

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Highest Temperature

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Days of Diarrhea

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hospitalized?

 

 

 

 

 

 

Admission Date

 

Discharge Date

 

 

Died?

 

 

 

 

Date of Death

Yes

No

 

 

 

 

/

 

/

 

 

 

 

/

/

 

 

 

 

Yes

No

Unk

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hospital Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is Patient Pregnant? Yes

No

If yes, # wks_____

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

School/Daycare Associated?

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

Outbreak Associated?

 

Yes

No

Name of School/Daycare:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Food Handler?

 

 

 

 

Yes

No

Person or Agency Completing form:

 

 

 

 

 

 

 

 

 

 

 

 

Attending Physician:

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

Agency:

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

Phone:

 

 

 

 

 

 

 

 

Date of Report:

/

/

 

 

Phone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LABORATORY INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

Name or Type of Test

Name of Laboratory

 

 

Specimen Source

 

 

Results

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDITIONAL INFORMATION FOR SEXUALLY TRANSMITTED DISEASES ONLY

 

 

 

Method of case detection:

Prenatal

Community & Screening Delivery

Instit. Screening

 

Reactor

Provider Report

 

Volunteer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Disease:

 

Stage

 

 

 

 

 

 

Disease:

 

Site: (Check all that apply)

 

 

 

 

Resistance:

 

Primary (lesion)

Secondary (symptoms)

 

Gonorrhea

 

Genital, uncomplicated

Ophthalmic

 

Penicillin

 

Syphilis

Early Latent

 

Late Latent

 

 

 

Chlamydia

 

Pharyngeal

 

 

 

 

 

PID/Acute

 

 

 

 

Tetracycline

 

Congenital

 

Other

 

 

 

Chancroid

 

Anorectal

 

 

 

 

 

Salpingitis

 

Other ___________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other___________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of spec.

Laboratory Name

 

 

Type of Test

 

Results

 

Treatment Date

 

Medication

 

 

 

 

Dose

 

Collection

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If syphilis, was previous treatment given for this infection?

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

If yes, give approximate date and place_______________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

902 KAR 2:020 requires health professionals to report the following diseases to the local health departments serving the jurisdiction in which the patient resides or to the Kentucky Department for Public Health (KDPH).

(Copies of 902 KAR 2:020 available upon request)

REPORT IMMEDIATELY by TELEPHONE to the Local Health Department or the KY Department for Public Health:

Unexpected pattern of cases, suspected cases or deaths which may indicate a newly recognized infectious agent

An outbreak, epidemic, related public health hazard or act of bioterrorism, such as SMALLPOX

Kentucky Department for Public Health in Frankfort

Telephone 502-564-3418 or 1-888-9REPORT (973-7678)

SECURED FAX 502-696-3803

REPORT WITHIN 24 HOURS

Anthrax

Hansen’s disease

Rubella

Arboviral Disease*

Hantavirus infection

Rubella syndrome, congenital

Neuroinvasive

Hepatitis A

Salmonellosis

Non-Neuroinvasive

Listeriosis

Shigellosis

Botulism

Measles

Syphilis, primary, secondary,

Brucellosis

Meningococcal infections

early latent or congenital

Campylobacteriosis

Pertussis

Tetanus

Cholera

Plague

Tularemia

Cryptosporidiosis

Poliomyelitis

Typhoid Fever

Diphtheria

Psittacosis

Vibrio parahaemolyticus

E. coli shiga toxin positive (STEC)

Q Fever

Vibrio vulnificus

Haemophilus influenzae

Rabies, animal

Yellow Fever

invasive disease

Rabies, human

 

REPORT WITHIN ONE (1) BUSINESS DAY

Foodborne outbreak

Hepatitis B, acute

Toxic Shock Syndrome

Hepatitis B infection in a

Mumps

Tuberculosis

pregnant woman or child

Streptococcal disease

Waterborne outbreak

born in or after 1992

invasive, Group A

 

REPORT WITHIN FIVE (5) BUSINESS DAYS

AIDS

HIV infection

Chancroid

Lead poisoning

Chlamydia trachomatis

Legionellosis

infection

Lyme disease

Ehrlichiosis

Lymphogranuloma venereum

Gonorrhea

Malaria

Granuloma inguinale

Rabies, post exposure

Hepatitis C, acute

prophylaxis

Histoplasmosis

 

Rocky Mountain spotted fever

Streptococcus pneumoniae,

drug-resistant invasive disease

Syphilis, other than primary, secondary, early latent or congenital

Toxoplasmosis

*Includes Eastern Equine, Western Equine, California group, St. Louis, Venezuelan and West Nile Viruses Influenza virus isolates are to be reported weekly by laboratories.

902 KAR 02:065 requires long term care facilities to report an outbreak (2 or more cases) of influenza-like illnesses (ILI) within 24 hours to the local health department or the KDPH.

All cases of HIV infections/AIDS are reportable to a separate surveillance system in accordance with KRS 211.180(1)b. To report a HIV/AIDS case call 866-510-0008.

DO NOT REPORT HIV/AIDS CASES ON THIS FORM.

Note: Animal bites shall be reported to local health departments within twelve (12) hours in accordance with KRS 258:065.