Virginia Epi 1 Form PDF Details

Keeping communities safe and healthy is a top priority, and part of that effort involves tracking various illnesses and conditions. This is where the Virginia Epi 1 form comes into play—a critical tool used by the Virginia Department of Health for this very purpose. Designed to facilitate the reporting of a wide array of diseases, from common flu to more severe conditions like tuberculosis or rabies, this form is a cornerstone of public health efforts in Virginia. Healthcare providers, including physicians and hospital personnel, as well as laboratory directors, are tasked with filling out and submitting this form to their local health department. The information requested covers everything from patient details, such as name and address, to specific data about the disease or condition, including symptoms, diagnosis dates, and any laboratory results. The goal is clear: by gathering detailed, confidential morbidity reports, the health department aims to monitor disease trends, control outbreaks, and ultimately protect the public's health. Reporting is not only a responsibility but a legal requirement for certain conditions, with specifics outlined in both the Code of Virginia and the Board of Health Regulations. Rapid reporting can be crucial for certain diseases, requiring immediate action to prevent further spread. Complementing these efforts, laboratories have a role in notifying health departments about positive test results and are encouraged to send initial samples to designated labs for further analysis. Such detailed and systematic reporting helps paint a clearer picture of public health trends across Virginia, guiding both preventive measures and responses to emerging health threats.

QuestionAnswer
Form NameVirginia Epi 1 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesvdh epi, virginia health dept epi form, vdh form report, virginia epi

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MAIL THE TOP TWO COPIES TO YOUR LOCAL HEALTH DEPARTMENT

VIRGINIA DEPARTMENT OF HEALTH

Confidential Morbidity Report

Patient's Name (Last, First, Middle Initial):

SSN: ___________-__________-____________

Home #: ( ) _________-___________

Patient's Address (Street, City or Town, State, Zip Code):

Work #: ( ) _________-___________

 

 

 

 

 

City or County of Residence

 

 

 

 

 

 

 

 

Date of Birth:

Age:

Race: American Indian/Alaskan Native

Asian

Hispanic:

Sex:

(mm/dd/yyyy)

 

Black/African American

Hawaiian/Pacific Islander

Yes

F

 

 

 

 

White

Unknown

 

 

 

No

M

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DISEASE OR CONDITION:

 

 

 

 

Pregnant:

Death: Yes

No

 

 

 

 

 

 

Yes

Death Date:

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unknown

 

 

Date of Onset:

Date of Diagnosis:

Influenza: (Report # and type only. No patient identification)

Number of Cases:

Type, if Known:

Physician's Name:

 

 

Phone #: (

) _________-___________

Address:

 

 

 

 

 

 

 

 

 

Hospital Admission:

Yes

No

Hospital Name:

 

Date of Admission:

 

 

Medical Record Number:

 

Laboratory Information and Results

Source of Specimen:

Laboratory Test(s) and Finding(s):

Date Collected:

Name/Address of Lab:

CLIA Number:

Other Information

Comments: (e.g., Risk situation [food handling, patient care, day care], Treatment [including dates], Immunization status [including dates], Signs/Symptoms, Exposure, Outbreak-associated, etc.)

Name, Address, and Phone Number of Person Completing this Form:

Date Reported:

Check here if you need more of these forms, or call your local health department.

(Be sure your address is complete.)

For Health Department Use

Date Received:

VEDSS Patient ID:

Please complete as much of this form as possible

Form Epi-1, 10/2011

MAIL THE TOP TWO COPIES TO YOUR LOCAL HEALTH DEPARTMENT

Please report the following diseases (and any other disease or outbreak of public health importance) in the manner required by Sections 32.1-36 and 32.1-37 of the Code of Virginia and 12 VAC 5-90-80 and 12 VAC 5- 90-90 of the Board of Health Regulations for Disease Reporting and Control. Enter as much information as possible on the reporting form.

Acquired immunodeficiency syndrome (AIDS) Amebiasis *

ANTHRAX *

Arboviral infection (e.g., dengue, EEE, LAC, SLE, WNV) *

BOTULISM * BRUCELLOSIS * Campylobacteriosis * Chancroid * Chickenpox (Varicella) * Chlamydia trachomatis infection *

CHOLERA *

Creutzfeldt-Jakob disease if <55 years of age * Cryptosporidiosis *

Cyclosporiasis *

DIPHTHERIA *

DISEASE CAUSED BY AN AGENT THAT MAY HAVE BEEN USED AS A WEAPON

Ehrlichiosis/Anaplasmosis *

Escherichia coli infection, Shiga toxin-producing * ^ Giardiasis *

Gonorrhea * Granuloma inguinale

HAEMOPHILUS INFLUENZAE INFECTION, INVASIVE * Hantavirus pulmonary syndrome *

Hemolytic uremic syndrome (HUS)

HEPATITIS A *

Hepatitis B (acute and chronic) * Hepatitis C (acute and chronic) * Hepatitis, other acute viral

Human immunodeficiency virus (HIV) infection * Influenza * #

(report INFLUENZA A, NOVEL VIRUS immediately)

INFLUENZA-ASSOCIATED DEATHS IN CHILDREN <18 YEARS OF AGE

Lead, elevated blood levels * Legionellosis *

Leprosy (Hansen disease) Listeriosis *

Lyme disease * Lymphogranuloma venereum Malaria *

MEASLES (RUBEOLA) * MENINGOCOCCAL DISEASE *

MONKEYPOX * Mumps *

MYCOBACTERIAL DISEASES (INCLUDING AFB),

(IDENTIFICATION OF ORGANISM) AND DRUG SUSCEPTIBILITY

Ophthalmia neonatorum

OUTBREAKS, ALL (including, but not limited to, foodborne, healthcare-associated, occupational, toxic substance-related and waterborne)

PERTUSSIS * PLAGUE *

POLIOVIRUS INFECTION, INCLUDING POLIOMYELITIS * PSITTACOSIS *

Q FEVER *

RABIES, HUMAN AND ANIMAL * Rabies treatment, post-exposure

RUBELLA, INCLUDING CONGENITAL RUBELLA SYNDROME * Salmonellosis *

SEVERE ACUTE RESPIRATORY SYNDROME (SARS) * Shigellosis *

SMALLPOX (VARIOLA) * Spotted fever rickettsiosis * Staphylococcus aureus infection

invasive methicillin-resistant (MRSA) * and vancomycin-intermediate or vancomycin-resistant *

Streptococcal disease, Group A, invasive or toxic shock * Streptococcus pneumoniae infection, invasive, in children <5 years

of age *

Syphilis (report PRIMARY and SECONDARY immediately) * Tetanus

Toxic substance-related illness * Trichinosis (Trichinellosis) *

TUBERCULOSIS (TB), ACTIVE DISEASE * Tuberculosis infection in children <4 years of age

TULAREMIA * TYPHOID/PARATYPHOID FEVER * UNUSUAL OCCURRENCE OF DISEASE OF

PUBLIC HEALTH CONCERN VACCINIA, DISEASE OR ADVERSE EVENT * VIBRIO INFECTION *

VIRAL HEMORRHAGIC FEVER * YELLOW FEVER *

Yersiniosis *

Report all conditions to your local health department when suspected or confirmed. Those in UPPER CASE must be reported immediately by the most rapid means available. All others must be reported within 3 days.

*These conditions are reportable by directors of laboratories. In addition, these and all other conditions except mycobacterial disease (other than TB) and invasive MRSA infection are reportable by physicians and directors of medical care facilities. Reports may be by computer- generated printout, Epi-1 form, CDC surveillance form, or upon agreement with VDH, by means of secure electronic transmission.

A laboratory identifying evidence of these conditions shall notify the health department of the positive culture and submit the initial isolate to the Virginia Division of Consolidated Laboratory Services (DCLS) or, for TB, to DCLS or other laboratory designated by the Board.

^Laboratories that use a Shiga toxin EIA methodology but do not perform simultaneous culture for Shiga toxin-producing E. coli should forward all positive stool specimens or positive enrichment broths to DCLS for confirmation and further characterization.

#Physicians and directors of medical care facilities should report influenza by number of cases only (report total number per week and by type of influenza, if known); however, individual cases of influenza A novel virus must be reported immediately by the most rapid means available.

Note: 1. Some healthcare-associated infections are reportable. Contact the VDH Healthcare-Associated Infections Program at (804) 864-8141 or see 12 VAC 5-90-370 for more information.

2.Cancers are also reportable. Contact the VDH Virginia Cancer Registry at (804) 864-7866 or see 12 VAC 5-90-150-180 for more information.

Virginia Department of Health

Office of Epidemiology

P.O. Box 2448, Suite 516-East Richmond, Virginia 23218-2448

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