Virginia Epi 1 Form PDF Details

If you're a small business owner in Virginia, it's essential to familiarize yourself with the state's unemployment insurance requirements. One of the most integral pieces of paperwork is called the "Epi 1 Form," and this document is used to inform new and existing employers about their obligations for ensuring their employees have access to proper benefits should they lose their job. In this post, you’ll learn more about the Virginia Epi 1 Form and how best to fill out your own copy in order to avoid any misunderstandings or penalties down the line.

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

Form Preview Example

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

How to Edit Virginia Epi 1 Form Online for Free

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Writing part 1 of form morbidity report

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