Form Pd 16 – Fill Out and Use This PDF

Form PD-16 (9/09)

NYC Department of Health & Mental Hygiene

U n i v e r s a l R e p o r t i n g F o r m

To order more copies of this form call the Provider Access Line: 1-866-NYC-DOH1

PHA No.

Patient Last Name

First Name

Medical Record Number

Amebiasis (Entamoeba histolytica only or cases in which E. histolytica cannot be distinguished from Entamoeba dispar.) **

Anaplasmosis

Formerly human granulocytic ehrlichiosis

Animal Bites (please fill out animal bite information below)

Exposure to rabies *

Including a bite or other exposure (e.g, scratch) to any animal confirmed to have rabies, or from any rabies vector species (raccoon, bat, skunk, fox or coyote), or any mammal exhibiting signs suggestive of rabies.

Animal Species: _____________________

Breed: __________________________

Color(s): _________________________

Date of Bite: ____ / ____ / ____

Area of body bitten __________________

Activity at time of bite ________________

Place of occurrence __________________

Treatment given: ___________________

Rabies prophylaxis	Yes	No
HRIG	Yes	No
Rabies Vaccine	Yes	No
Animal Owned	Stray	Unknown

Animal’s owner (last name, first name):

______________________________

Address (Street, Apt.):

______________________________

Boro/City, State, Zip:

______________________________

Telephone Number:

( ______ ) ______ – _____________

Anthrax *

Arboviral Infections *

Specify which virus: __________________

If Dengue, West Nile or Yellow Fever, report as such. Attach copies of diagnostic laboratory results if available.

Babesiosis

Babesiosis can be transmitted through blood products. If patient has a history of receiving blood transfusion or donating blood within 3 months of onset of illness, report suspected/confirmed cases immediately.*

Botulism *

Foodborne Wound Infant

Brucellosis *

Campylobacteriosis **

Chancroid: see STD section, page 3

Chlamydia: see STD section, page 3

Cholera */**

Creutzfeld-Jakob Disease: see Transmissible Spongiform Encephalopathy

Cryptosporidiosis **

Cyclospora **

Dengue

Attach copies of diagnostic laboratory results if available.

Drowning

Respiratory impairment from submersion/immersion in liquid.

Drowning Location: __________________

Outcome: Death Morbidity No Morbidity

Diphtheria *

Ehrlichiosis, Human monocytic ehrlichiosis

If human granulocytic anaplasmosis report as anaplasmosis.

Encephalitis

Jul.1–Oct. 31 consider and test for West Nile virus. If due to another reportable disease (e.g. Lyme, West Nile, arbovirus), report under the other disease.

Escherichia coli O157:H7 **

Escherichia coli (other) Shiga Toxin Producing **

Giardiasis **

Glanders *

Gonorrhea: see STD section, page 3

Granuloma Inguinale: see STD section, page 3

Hantavirus *

Hemolytic Uremic Syndrome

Hemophilus influenzae, invasive only Specimen Source:

Blood CSF Unknown

Other_______________________

Specify Serotype:

Type B	Not typeable
Not tested	Unknown

Other_______________________

FOR ALL HEPATITIS REPORTS:

Jaundice Yes No Unknown

ALT (SGPT) value: _____________ Unknown

Lab reference range: ___________ Unknown

Hepatitis A */**

Total Ab to Hepatitis A is NOT reportable

IgM anti-HAV: Pos Neg Unknown

Hepatitis B

Report at least one positive hepatitis B test result: Total Ab to Hepatitis B is NOT reportable

IgM anti-HBc Pos Neg Unknown If positive, describe symptoms and risks in comments box on page 1 and indicate sexual part- ners in the past year (Check only one)

Males only		Females only
Males and Females		Unknown
HBsAg:	Pos	Neg	Unknown
HBeAg:	Pos	Neg	Unknown
HBV Nucleic Acid:	Pos	Neg	Unknown

Cases in pregnant women must be reported on the IMM5 or via

Reporting Central. For information call 718-520-8245.

Hepatitis C

Check all that apply:

EIA with high s/co value: _____________

RIBA pos. HCV Nucleic Acid (e.g.PCR) pos

Is this an acute/new infection? Yes No Unk

Hepatitis D

Hepatitis E

Hepatitis other/Unspecified

For hepatitis D, E, and other/unspecified, please describe in comments box on Page 1.

Herpes, Neonatal: see STD section, page 3

HIV/AIDS. For assistance in reporting a case of HIV/AIDS, to receive the required New York State Provider Report Forms (PRF), or to obtain more information, call (212) 442-3388.

Influenza Check all that apply:

Suspected novel viral strain with pandemic potential (e.g. H5) *

Death in a child younger than 18 years of age

Kawasaki Syndrome

Legionellosis, Specify positive test:

Culture Urine antigen

DFA

Serology

Leprosy (Hansen’s Disease)

Leptospirosis

Listeriosis

Lyme Disease

Erythema migrans present? Yes No Unknown

Lymphocytic Choriomeningitis Virus

Lymphogranuloma Venereum: see STD section on Page 3

Malaria ** Select at least one of the following:

falciparum vivax malariae

ovale undetermined

Measles *

Melioidosis *

Meningitis, Aseptic/Viral

Jul.1–Oct. 31 consider and test for West Nile virus. If due to another reportable disease (e.g. Lyme, West Nile, arbovirus), report under the other disease.

Meningitis, other bacterial

Specify Organism: ___________________

Meningococcal Disease, Invasive * Test type/Specimen source:

Blood culture	CSF Culture
Antigen test from CSF	Gram stain

Other________________________

Monkeypox *

Mumps

Pertussis for hospitalized cases*

Plague *

Poisoning: see Poisoning section, page 3

Polio *

Psittacosis

Q Fever *

Rabies *

Ricin *

Rickettsialpox

Rocky Mountain Spotted Fever

Rubella

for an IgM positive case in pregnant women*

Rubella, Congenital Syndome

Salmonellosis ** Serogroup: _______

If due to Salmonella typhi or paratyphi, select Typhoid/Paratyphoid Fever

SARS (Severe Acute Respiratory Syndrome) *

Shigellosis **

Smallpox *

Staph Enterotoxin B *

Staphylococcus aureus, vancomycin intermediate and resistant *

Source: ____________________

MIC (∝g/ml): _________________

Streptococcus (Group A) Invasive only

Specify Source: Blood CSF Unknown

Other, Specify: ___________________

Streptococcus (Group B) Invasive only

Specify Source: Blood CSF Unknown

Other, Specify: ___________________

Syphilis: see STD section, page 3

Tetanus

Toxic shock syndrome, For staph only. For strep select Streptococcus (Group A).

Trachoma

Transmissible Spongiform Encephalopathy Creutzfeld-Jakob Disease and variants

Testing done: ______________________

(e.g. 14-3-3 on CSF, brain biopsy, autopsy, EEG/MRI)

Trichinosis: Caused by bacterium Trichinella spiralis. (Trichomoniasis, caused by Trichomonas vaginalis, need not be reported.)

Tuberculosis: see TB section on page 4

Tularemia *

Typhoid /Paratyphoid Fever **

Vaccinia disease (adverse events associated with smallpox vaccination) *

Vibrio spp. *

Specify species: ____________________

Viral Hemorrhagic Fever *

West Nile Virus * Attach copies of diagnostic labora- tory results if available

Window Falls.

Falls from windows of buildings with three or more apartments, by children aged ten years and younger,

report on yellow Child Window Fall Notification Report. For assistance call 1-866-NYC-DOH1

Yellow Fever * Attach copies of diagnostic labora- tory results if available

Yersiniosis ** non-plague

Page 2

* Report suspected/confirmed cases immediately 1-866-NYC-DOH1, after hours 1-212-764-7667; Report all other results within 24 hours.

** Please complete Risk Groups section on front of form.

Patient Last Name

First Name	Medical Record Number

POISONINGS

MODE OF EXPOSURE	TYPE			QUANTITY			REASON	Intentional
Ingestion				Milliliter (mL) _______			Unintentional	Suspected suicide
	Lead For persons aged 16 and older indicate:
Ocular				Mouthful _______			General	Misuse
	Employer _______________________							Abuse
							Environmental
Dermal
	Employer Phone:			Sip _______			Therapeutic	Unknown
Inhalation	( _____ ) _____ – ____________			Tablespoon _______			Misuse	Other
Aural							Bite/sting
								Contamination/
	Arsenic	Cadmium Carbon Monoxide*		Tab/pill/cap _______			Food poisoning
Bite									tampering
							Occupational
	Mercury	Pesticide		Taste/lick/drop_______				Malicious
Sting							Dietary
								Withdrawal
IV	Other ________________________			Teaspoon _______			Consumer product
	Other ________________________			Unknown			Unknown	Adverse reaction
								Drug
SPECIMEN SOURCE				TIME OF EXPOSURE				Food
Capillary Venous Urine		Laboratory Accession Number		____ ____ : ____ ____				Other
								Unknown
Other _____________		____________________		AM	PM
Date Collected		Results (units) ___________		VITAL SIGNS
____ / ____ / ______				Body Weight _________		Resp: _______			Pupils:
		Purpose of test
Date Analyzed				Pounds	Kilograms	Temp: _______ F C			Dilated
		Initial Repeat							Constricted
____ / ____ / ______		Follow-up		BP: __ __ __/ __ __ __		Pulse: __________

SYMPTOM ASSESSMENT (Check all that apply)

	None	Electrolyte abnormalities
	Nausea/vomiting/diarrhea	Cough/shortness of breath
	Lethargic/stupor/coma	Occular irritation
	Agitated	Skin irritation
	Hypertensive	Unknown
	Hypotensive	Other
	Tachycardia	__________________
	Brachycardia
	Seizure
	PROVIDER TREATMENT
	No therapy required	Irrigated eye
	Oral fluids	Oxygen
	Emesis	Naxolone
	Lavage	50% Dextrose/Thiamine
	Activated charcoal	Alkalinize urine
	Cathartic	N-acetylcysteine (Mucromyst)
	Chelation	Other:
	Insect sting mgmt.	__________________

FOR ALL STD REPORTS

As of the date of this report,

☛Were any of this patient’s sex partners notified of possible exposure to a sexually transmitted disease?

Yes, our office notified the partner(s)

Yes, the patient was asked to notify partner(s)

No

Unknown

☛Did you provide treatment for any of this patient’s sex partners?

Yes, I gave extra medication/prescription for the sex partner(s)

If yes, for how many sex partners was medication/ prescription provided? ______________

Yes, I saw the sex partner(s) in my office

No

Unknown

☛For all sexually transmitted diseases, indicate sexual partners in past year (Check only one)

Males only	Females only
Males and Females	Unknown

Chancroid Specify specimen source:

Penile	Vaginal	Endocervical
Anorectal	Oropharyngeal

Other ________________________

Specimen collection date ___ / ___ / ____

Treatment __________________________

Treatment date ___ / ___ / _____ Unknown

Chlamydia (CT) Specify specimen source:

Endocervical	Urethral Anorectal
Oropharyngeal	Urine

Other ________________________

Specify test type:

Culture

Nucleic acid amplification

Nucleic acid hybridization

EIA DFA

Other: ______________________

Specimen collection date ___ / ___ / ____

Treatment ________________________

Treatment date ___ / ___ / _____ Unknown

Gonorrhea (GC) Specify specimen source:

Endocervical	Urethral Anorectal
Oropharyngeal	Urine

Other ________________________

Specify test type:

Culture

Nucleic acid amplification

Nucleic acid hybridization

Other: ______________________

Specimen collection date ___ / ___ / ____

Treatment __________________________

Treatment date ___ / ___ / _____ Unknown

Granuloma Inguinale Specify specimen source:

Penile	Vaginal	Endocervical
Anorectal	Oropharyngeal

Other ________________________

Specimen collection date ___ / ___ / ____

Treatment __________________________

Treatment date ___ / ___ / _____ Unknown

Herpes, Neonatal

Herpes simplex virus infection in infants aged 60 days or less.

Clinical dx

Lab confirmed dx: Culture PCR

Antigen detection Serologic Tzanck Herpes type: Type 1 Type 2 Not typed

Clinical Syndrome (check all that apply):

Skin, eye, mucous membrane infection

CNS involvement	Disseminated disease
Herpes lesions present?

Yes, anatomic site ________________

No Unknown

Specimen collection date ___ / ___ / ____

Treatment for infant ___________________

Treatment date ___ / ___ / ____ Unknown

Mother’s Name: ____________________

Mother’s DOB: ____ / ____ / ______

Lymphogranuloma Venereum

Clinical Presentation (Check all that apply):

Proctitis Lymphadenopathy Skin lesion

Buboe

Other _________________________

Specimen collection date ___ / ___ / ____

Treatment __________________________

Treatment date ___ / ___ / _____ Unknown

Syphilis Stage:

Congenital

Primary (chancre present) check all that apply

Penile Vaginal Endocervical

Anorectal Oropharyngeal

Other _____________________

Secondary

Alopecia Condylomata

Mucous patches Rash

Early Latent

(no symptoms, infection ≤ 1 year duration)

Late Latent

(no symptoms, infection of > 1 year duration)

Tertiary (gumma or cardiovascular)

Neurologic	symptoms present?
Yes	No Unknown

Treatment :

List Medication and Dosage:

________________________________

Treatment date ___ / ___ / ___ Unknown

Syphilis Test Types. Check all that apply 1. Serologic tests for syphilis

A. Non-treponemal Test

RPR

Reactive Non-reactive Titer _________________

VDRL

Reactive Non-reactive Titer _________________

Specimen collection date ___ / ___ / ____

B. Treponemal Test

TP-PA/MHA-TP Reactive Non-reactive

FTA	Reactive	Non-reactive
Treponemal IgG	Reactive	Non-reactive

Specimen collection date ___ / ___ / ____

2.Cerebrospinal fluid tests

CSF VDRL

Reactive Non-reactive

CSF FTA

Reactive Non-reactive

Other Test: _____________________

Result: _____________________

Specimen collection date ___ / ___ / ____

Elevated CSF protein

Yes

No

Elevated CSF leukocytes

Yes No

Specimen collection date ___ / ___ / ____

3. Organism visualization

Darkfield

Positive Negative

Other test: ____________________

Result: _____________________

Specimen collection date ___ / ___ / ____

* Report suspected/confirmed cases immediately 1-866-NYC-DOH1, after hours 1-212-764-7667; Report all other results within 24 hours.

** Please complete Risk Groups section on front of form.

Page 3

Patient Last Name

First Name

Medical Record Number

Tuberculosis Check all that apply
Primary disease site:		Other sites:
	Pulmonary		Pulmonary
	Lymphatic		Lymphatic
	Bone/Joint		Bone/Joint
	Soft tissue/Muscles		Soft tissue/Muscles
	Peritoneal		Peritoneal
	Meningeal		Meningeal
	Genitourinary		Genitourinary
	Gastronintestinal		Gastronintestinal
	Other:		Other:
____________		_____________

Laboratory Results:

Specimen Number ___________________

AFB Smear

Positive

Smear Grade: suspicious

1+ rare

2+ few

3+ moderate 4+ numerous

	Negative		Pending
	Not Done		Unknown
M. tb Culture			Negative
	Positive
	Pending		Contaminated
	Not Done		Unknown

Nucleic Acid Amplification (NAA)

Test Type:

TB Screening Test

Test Type:

History of Positive TST

TST, Size _____________ mm

Positive Negative Date Implanted

____ / ____ / ______

QuantiFERON® TB-Gold (QFT-G)

Positive

Negative

Indeterminate or Invalid

QuantiFERON® TB-Gold in tube (QFT-GIT)

Positive

Negative

Indeterminate or Invalid

T-Spot.TB

Positive

Negative

Borderline (equivocal)

Indeterminate or Invalid

Date blood drawn

____ / ____ / ______

Other: ________________________

Not done

Unknown

Unknown

Specimen Source:

Sputum

Tracheal aspirate

Bronchial fluid/Broncho-alveolar lavage

Lymph node

Lung tissue

Pleural fluid

Pleura

Blood

Urine

Other: ________________________

Collection date ___ / ___ / _____ Unknown

Testing Laboratory:_ ___________________

Unknown

MTD Amplicor Not Done Unknown

Other: _____________________

Test Result:

Positive		Negative Pending
Not Done		Unknown
Pathology consistent with TB
Positive		Negative
Not Done		Unknown
Pathology findings: ___________________
_______________________________
_______________________________
Chest X-Ray ___ / ___ / _____
	Normal		Abnormal
	Miliary		Non-Cavitary
	Cavitary		Consistent with TB
			Not consistent with TB
CT Scan / MRI			___ / ___ / _____
	Normal		Abnormal
	Miliary		Non-Cavitary
	Cavitary		Consistent with TB
			Not consistent with TB

Treatment
On Anti-TB Medications		Yes No				Unknown
Please complete for each medication:							Dose	Start Date
	Isoniazid (INH)							____ / ____ / ______
	Rifampin (RIF)							____ / ____ / ______
	Pyrazinamide (PZA)							____ / ____ / ______
	Ethambutol (EMB)							____ / ____ / ______
	Other 1							____ / ____ / ______
	Other 2							____ / ____ / ______
	Other 3							____ / ____ / ______
Isolation:		Yes					No	Unknown

Other Medical Problems/Other Pertinent Information: