Form Ph1600 Tennessee – Fill Out and Use This PDF

Tennessee Department of Health Reportable Diseases and Events

The diseases and events listed on the back of this report are declared to be communicable and/or dangerous to the public and are to be reported to the local health department by all hospitals, physicians, laboratories, and other persons knowing of or suspecting a case in accordance with the provision of the statutes and regulations governing the control of communicable diseases in Tennessee (T.C.A. §68 Rule 1200-14-01-.02). For more specific details, download the Reportable Diseases and Events Matrix (http://health.state.tn.us/ceds/notifiable.htm). If further guid- ance is needed, contact Communicable and Environmental Disease Services at (615) 741-7247 or (800) 404-3006.

Disease/Event Code:
	Patient Name:
	Date of Birth:			Race: □ American Indian / Alaskan
	____/____/________					□ Asian
Demographics	Gender:	□ Male				□ Black / African American
		□ Female				□ Hawaiian / Pacific Islander
						□ White
	Ethnicity: □ Hispanic
						□ Other (_________________)
		□ Not Hispanic
	Street Address:
	City:							State:
	County:							Zip Code:
	Phone: (	)
	Onset Date: ____/____/________
Information
	Died?:	□ Yes				Pregnant?:		□ Yes
	Hospitalized?: □ Yes					Admission Date: ____/____/________
		□ No
		□ Unknown				Discharge Date: ____/____/________
Clinical		□ No						□ No
		□ Unknown						□ Unknown
	STD Treatment Date:					STD Treatment:
	____/____/________
Provider	Physician Name:
	Facility/Hospital Name:
	Phone: (	)
Laboratory	Test:
	Specimen Collection Date:				Result:
	____/____/________
	Specimen Source:

Disease/Event Code:
	Patient Name:
	Date of Birth:			Race: □ American Indian / Alaskan
	____/____/________					□ Asian
Demographics	Gender:	□ Male				□ Black / African American
		□ Female				□ Hawaiian / Pacific Islander
						□ White
	Ethnicity: □ Hispanic
						□ Other (_________________)
		□ Not Hispanic
	Street Address:
	City:							State:
	County:							Zip Code:
	Phone: (	)
	Onset Date: ____/____/________
Information
	Died?:	□ Yes				Pregnant?:		□ Yes
	Hospitalized?: □ Yes					Admission Date: ____/____/________
		□ No
		□ Unknown				Discharge Date: ____/____/________
Clinical		□ No						□ No
		□ Unknown						□ Unknown
	STD Treatment Date:					STD Treatment:
	____/____/________
Provider	Physician Name:
	Facility/Hospital Name:
	Phone: (	)
Laboratory	Test:
	Specimen Collection Date:				Result:
	____/____/________
	Specimen Source:

[006]Brucellosis (Brucella species)B

[010]Congenital Rubella Syndrome

[011]Diphtheria (Corynebacterium diphtheriae)

[121]Encephalitis, Arboviral: California/LaCrosse Serogroup

[123]Encephalitis, Arboviral: Eastern Equine

[122]Encephalitis, Arboviral: St. Louis

[124]Encephalitis, Arboviral: Western Equine

[506]Enterobacteriaceae, Carbapenem-resistant

[053]Group A Streptococcal Invasive Disease (Streptococcus pyogenes)

[047]Group B Streptococcal Invasive Disease (Streptococcus

agalactiae)

[054]Haemophilus influenzae Invasive Disease

[016]Hepatitis, Viral-Type A acute

[513]Influenza-associated deaths, age <18 years

[520]Influenza-associated deaths, pregnancy-associated

Category 2: Requires written report using form PH-1600 within 1 week.

[501]Babesiosis

[003]Botulism-Infant (Clostridium botulinum)

[007]Campylobacteriosis (including EIA or PCR positive stools)

[503]Chagas Disease

[069]Chancroid

[055]Chlamydia trachomatis-Genital

[057]Chlamydia trachomatis-Other

[056]Chlamydia trachomatis-PID

[009]Cholera (Vibrio cholerae)

[001]Cryptosporidiosis (Cryptosporidium species)

[106]Cyclosporiasis (Cyclospora species)

[504]Dengue Fever

[116]Ehrlichiosis-HGE (Anaplasma phagocytophilum)

[051]Ehrlichiosis-HME (Ehrlichia chaffeensis)

[117]Ehrlichiosis/Anaplasmosis-Other

[060]Gonorrhea-Genital (Neisseria gonorrhoeae)

[064]Gonorrhea-Opthalmic (Neisseria gonorrhoeae)

[061]Gonorrhea-Oral (Neisseria gonorrhoeae)

[063]Gonorrhea-PID (Neisseria gonorrhoeae)

[062]Gonorrhea-Rectal (Neisseria gonorrhoeae)

[133]Guillain-Barré syndrome

[058]Hemolytic Uremic Syndrome (HUS)

[480]Hepatitis, Viral-HbsAg positive infant

[048]Hepatitis, Viral-HbsAg positive pregnant female

[017]Hepatitis, Viral-Type B acute

[018]Hepatitis, Viral-Type C acute

[021]Legionellosis (Legionella species)

[022]Leprosy [Hansen Disease] (Mycobacterium leprae)

[094]Listeriosis (Listeria species)

[024]Lyme Disease (Borrelia burgdorferi)

[025]Malaria (Plasmodium species)

[515]Melioidosis (Burkholderia pseudomallei)

[102]Meningitis-Other Bacterial

[031]Mumps

[033]Plague (Yersinia pestis)B

[035]Poliomyelitis-Nonparalytic

[034]Poliomyelitis-Paralytic

[119]Prion disease-variant Creutzfeldt Jakob Disease

[109]Q Fever (Coxiella burnetii)B

[040]Rubella

[041]Salmonellosis: Typhoid Fever (Salmonella Typhi)

[131]Staphylococcus aureus: Vancomycin non-sensitive – all forms

[075]Syphilis (Treponema pallidum): Congenital

[519]Tuberculosis, confirmed and suspect cases of active disease

(Mycobacterium tuberculosis complex)

[113]Tularemia (Francisella tularensis)B

[118]Prion disease-Creutzfeldt Jakob Disease

[036]Psittacosis (Chlamydia psittaci)

[105]Rabies: Animal

[042]Salmonellosis: Other than S. Typhi (Salmonella species)

[517]Shiga-toxin producing Escherichia coli (including Shiga-like

toxin positive stools, E. coli O157 and E. coli non-O157)

[043]Shigellosis (Shigella species)

[039]Spotted Fever Rickettsiosis (Rickettsia species including Rocky

Mounted Spotted Fever)

[130]Staphylococcus aureus: Methicillin resistant Invasive Disease

[518]Streptococcus pneumoniae Invasive Disease (IPD)

[074]Syphilis (Treponema pallidum): Cardiovascular

[072]Syphilis (Treponema pallidum): Early Latent

[073]Syphilis (Treponema pallidum): Late Latent

[077]Syphilis (Treponema pallidum): Late Other

[076]Syphilis (Treponema pallidum): Neurological

[070]Syphilis (Treponema pallidum): Primary

[071]Syphilis (Treponema pallidum): Secondary

[078]Syphilis (Treponema pallidum): Unknown Latent

[044]Tetanus (Clostridium tetani)

[045]Toxic Shock Syndrome: Staphylococcal

[097]Toxic Shock Syndrome: Streptococcal

[046]Trichinosis

[101]Vancomycin resistant enterococci (VRE) Invasive Disease

[114]Varicella deaths

[104]Vibriosis (Vibrio species)

[125]West Nile virus Infections-Encephalitis

[126]West Nile virus Infections-Fever

[098]Yellow Fever

[103]Yersiniosis (Yersinia species)