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C HEALTH AGENCY USE ONLY CONDITION I.D. OUTBREAK I.D. DISEASE CASE REPORT Patient Information PATIENT IDENTIFIER PATIENT S COUNTRY OF ORIGIN DATE ARRIVED IN USA OCCUPATION HOME TELEPHONE WORK TELEPHONE PARENT OR GUARDIAN MARITAL STATUS SEX Male Female RACE/ETHNICITY (CHECK ALL THAT APPLY) AMERICAN INDIAN ASIAN BLACK ADDRESS YES PACIFIC ISLANDER UNKNOWN WHITE OTHER RACE Specify: NO UNK CITY, STATE, ZIP CODE COUNTY OF RESIDENCE YES WAS PATIENT HOSPITALIZED? YES Repo.

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Contact information for local health departments can be accessed at .ncalhd.org/directors. If you are unable to contact your local health department, call the 24/7 pager for N.C. Communicable Disease Branch (919) 733-3419.

If you think you or someone you know may have a communicable disease, you should contact your health care provider right away. Your health care provider will be able to give you information regarding the condition and guidance for steps to follow to prevent, diagnose, or treat an infection, if necessary.

In cases of immediately reportable diseases and other emergencies and if the local health department cannot be reached, the New Jersey Department of Health maintains an emergency after hours phone number: 609-392-2020.

Registered medical practitioners have a statutory duty to notify the 'proper officer' at their local council or local health protection team (HPT) of suspected cases of notifiable diseases. They must: Complete a notification form immediately on diagnosis of a suspected notifiable disease.

Immediate reporting is required for potential bioterrorism-related diseases, such as anthrax and botulism; the severe or highly communicable diseases, such as cholera and cryptosporidiosis, must be reported within 24 hours of diagnosis; other diseases and conditions, such as mumps and chlamydia, have a seven-day ...

Communicable diseases, also known as infectious diseases or transmissible diseases, are illnesses that result from the infection, presence and growth of pathogenic (capable of causing disease) biologic agents in an individual human or other animal host.

Information. All US states have a reportable diseases list. It is the responsibility of the health care provider, not the patient, to report cases of these diseases. Many diseases on the list must also be reported to the US Centers for Disease Control and Prevention (CDC).

Some examples of the reportable communicable diseases include Hepatitis A, B & C, influenza, measles, and salmonella and other food borne illnesses.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232