Maryland Confidential Morbidity Report Form PDF Details

In Maryland, the Confidential Morbidity Report (DHMH 1140) serves as a crucial tool for physicians and other healthcare providers (excluding laboratories, which use different forms) to report a wide array of conditions and diseases to the local health department. This comprehensive form encompasses vital patient information, including demographic details such as name, date of birth, sex, ethnicity, and race, contact numbers, and addresses. It further delves into the patient’s occupation, potential contact with vulnerable populations, and specifics about the workplace or other communal settings like schools or childcare facilities. Critical to public health surveillance and intervention, the form enables detailed reporting on the disease or condition in question, including the date of onset, hospital admission details, notification status of the patient, suspected source of infection, and, in unfortunate cases, death. For expectant mothers, it queries pregnancy status, which is pivotal for tracking and mitigating risks associated with congenital conditions. Moreover, the form allocates space for the inclusion of laboratory tests for viral hepatitis and other pertinent clinical information, which may include results for HIV and AIDS, shedding light on secondary infections and conditions attributed to HIV infection. The form also covers sexually transmitted infections (STIs) with sections dedicated to specific diseases like syphilis, gonorrhea, chlamydia, and others, urging healthcare providers to detail laboratory confirmations and treatments administered. Notably, it incorporates a component for tuberculosis, highlighting the importance of distinguishing between pulmonary, extrapulmonary, and atypical manifestations. By requesting assistance from the local health department for patient notification and partner services, the form underscores the collaborative effort between healthcare providers and public health entities to control infectious diseases and safeguard community health.

QuestionAnswer
Form NameMaryland Confidential Morbidity Report Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesmaryland morbidity and mortality form, printable md morbidity report, maryland morbidity report, MARYLAND

Form Preview Example

MARYLAND CONFIDENTIAL MORBIDITY REPORT (DHMH 1140)

(For use by physicians and other health care providers, but not laboratories. Laboratories should use forms DHMH 1281 & DHMH 4492.)

SEND TO YOUR LOCAL HEALTH DEPARTMENT

STATE DATA BASE NUMBER (Completed by Health Department)

NAME OF PATIENT

– LAST

FIRST

 

M

 

 

 

 

 

 

DATE OF BIRTH

 

AGE

SEX

 

ETHNICITY (Select independently of RACE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MONTH

 

DAY

 

 

YEAR

 

 

M

 

HISPANIC or LATINO:

YES

 

NO

UNKNOWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TELEPHONE NUMBERS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RACE (Select one or more. If multiracial, select all that apply)

Home:

 

 

 

 

 

 

 

Workplace:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

American Indian/Alaskan Native

 

Asian

Black/African American

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hawaiian/Pacific Islander

 

White

 

Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (Specify):

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

UNIT#

 

 

CITY OR TOWN

 

 

 

 

 

 

 

 

 

 

 

STATE

 

 

ZIP CODE

 

 

COUNTY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OCCUPATION OR CONTACT WITH VULNERABLE PERSONS

 

 

 

WORKPLACE, SCHOOL, CHILD CARE FACILITY, ETC.

 

( Include Name, Address, ZIP Code)

 

 

 

(Check all that apply - include volunteers)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HEALTH CARE WORKER (Include any PATIENT CARE, ELDER CARE, "AIDES," etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DAYCARE (Attendee or Worker)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PARENT of a child in DAYCARE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FOOD SERVICE WORKER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOT EMPLOYED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER (SPECIFY):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DISEASE OR CONDITION

 

 

 

 

 

 

 

 

 

 

DATE OF ONSET

ADMITTED

 

 

DATE ADMITTED

 

HOSPITAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MONTH

 

 

DAY

 

YEAR

YES

 

MONTH

 

 

DAY

 

YEAR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PATIENT HAS BEEN NOTIFIED OF THIS CONDITION

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONDITION ACQUIRED IN MARYLAND

SUSPECTED SOURCE OF INFECTION

 

 

 

 

 

 

 

 

 

 

 

 

 

DIED

 

 

 

 

DATE DIED

 

PREGNANT

 

 

 

YES

NO

 

UNKNOWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

MONTH

DAY

 

YEAR

 

YES

NO

UNKNOWN

NOT APPLICABLE

(IF NO, INTERSTATE , or INTERNATIONAL )

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

WEEKS PREGNANT __________

DUE DATE ____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LABORATORY TESTS - VIRAL HEPATITIS

 

LABORATORY TESTS - VIRAL HEPATITIS

 

 

 

 

LABORATORY TESTS - VIRAL HEPATITIS

 

ADDITIONAL LAB RESULTS

 

 

 

POS

NEG

DATE

 

 

 

POS

NEG

 

 

DATE

 

 

 

 

HCV Viral Genotyping

____________

DATE _____________

 

(SPECIMEN - TEST - RESULT - DATE - NAME of LAB)

 

 

 

 

 

 

 

 

 

 

 

 

(Please attach copies of lab reports whenever possible.)

HAV Antibody Total

_____________________

 

HBV surface Antibody

_____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ALT (SGPT) Level

______________

DATE

______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HAV Antibody IgM

_____________________

 

HBV Viral DNA

_____________________

 

 

 

ALT – Lab Normal Range:

______________ to _____________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HBV surface Antigen

_____________________

 

HCV Antibody ELISA

_____________________

 

 

 

AST (SGOT) Level

____________

DATE _____________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HBV e Antigen

 

_____________________

 

HCV ELISA Signal/Cut Off Ratio

 

_____________________

 

 

 

AST – Lab Normal Range: ______________ to

____________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HBV core Antibody Total

_____________________

 

HCV Antibody RIBA

_____________________

 

 

 

NAME of LAB:

________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HBV core Antibody IgM

_____________________

 

HCV RNA (eg., by PCR)

_____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PERTINENT CLINICAL INFORMATION + OTHER COMMENTS

 

HUMAN IMMUNODEFICIENCY VIRUS (HIV) and

–

ADDITIONAL CASE INFORMATION

 

ACQUIRED IMMUNODEFICIENCY SYNDROME

(AIDS)

 

CON D IT IO NS

 

H IV L AB T EST S

 

D AT E

RESULT

 

WEIGHT LOSS OR DIARRHEA .............................................

CD4+

T-cells < 200 per microliter or < 14%

 

 

 

SECONDARY INFECTIONS (PCP, TB, etc.).........................

 

 

 

 

 

 

 

ELISA

 

 

 

 

 

 

PERINATAL EXPOSURE OF NEWBORN .............................

 

 

 

 

 

 

WESTERN BLOT

 

 

 

 

 

OTHER CONDITIONS ATTRIBUTED TO HIV INFECTION (SPECIFY):

 

 

 

 

 

 

OTHER (SPECIFY):

 

 

 

 

PHYSICIAN REQUESTS LOCAL HEALTH DEPARTMENT TO ASSIST WITH: NOTIFICATION TO PATIENT YES NO PARTNER SERVICES YES NO

SEXUALLY TRANSMITTED INFECTION (STI) –

ADDITIONAL CASE INFORMATION

SYPHILIS: PRIMARY

SECONDARY

EARLY LATENT (LESS THAN 1 YR)

CONGENITAL

OTHER STAGE (SPECIFY):

 

 

 

 

 

 

GONORRHEA: CERVICAL

URETHRAL

RECTAL

PHARYNGEAL

OPHTHALMIA NEONATORUM

PID OTHER (SPECIFY):

 

 

 

 

 

 

CHLAMYDIA: CERVICAL

URETHRAL

RECTAL

PHARYNGEAL

PID

OTHER (SPECIFY):

 

 

 

 

 

 

 

OTHER STI (Specify):

 

 

 

 

 

 

STI LABORATORY CONFIRMATION AND TREATMENT

Specify STI Lab Test (e.g., RPR Titer, FTA – TPPA, Darkfield, Smear, Culture, NAAT, EIA, VDRL - CSF)

DATE

TEST

RESULT

STI Treatment Given (Specify date – drug – dosage below)

No Treatment Given

DATE

DRUG

DOSAGE

TUBERCULOSIS (Suspect or Confirmed) – ADDITIONAL CASE INFORMATION

MAJOR SITE: PULMONARY

EXTRAPULMONARY

ATYPICAL (SPECIFY )

ABNORMAL CHEST X-RAY:

COMMENTS:

REPORTED BY

ADDRESS

TELEPHONE NUMBER

DATE OF REPORT

MONTH DAY YEAR

Check here if completed by the Health Department

NOTES: Your local health department may contact you following this initial report to request additional disease-specific information. To print blank report forms or get more information about reporting, go to http://ideha.dhmh.maryland.gov/SitePages/what-to-report.aspx.

DHMH 1140 REVISED JANUARY 26, 2012

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