Get Confidential Communicable Disease Report Part 1 Fill In Form

The Confidential Communicable Disease Report Part 1 Fill In Form is a crucial document used by healthcare professionals to report communicable diseases to local health departments. Completing this form accurately is essential for public health management.

Follow the steps to successfully complete the form online.

1. To begin, click the ‘Get Form’ button to access the fillable version of the form in your preferred editing platform.
2. Enter the NC Disease Code number corresponding to the disease under report. You may reference the list of NC Disease Code numbers provided in the form.
3. Provide demographic information about the patient: enter the patient's last name and first name, birthdate in the format (dd/mm/yyyy), sex, and if applicable, parent or guardian's details for minors.
4. Include the Patient Identifier; this can be the medical chart number or another identifier, but it is optional. Additionally, only fill in the Social Security Number if it is known to be accurate.
5. Fill in the patient's address including the city, state, and zip code, along with their current county of residence. Provide a phone number at which the patient can be contacted.
6. Indicate the patient’s age: enter age in months if the patient is less than 12 months and in years if they are 12 months or older.
7. Complete the race and ethnic origin sections as required.
8. State whether the patient was hospitalized due to this disease for more than 24 hours by entering ‘Yes’ if applicable.
9. Indicate if the patient died from this disease by putting ‘Yes’ only if it was the primary cause of death.
10. Note if the patient is currently pregnant by entering ‘Yes’ if applicable.
11. Provide details on patient associations, which is especially critical for respiratory and enteric diseases, and specify the geographic location where the patient was most likely exposed to the disease.
12. Indicate if the patient exhibited symptoms of the disease by entering ‘Yes’. Include the symptom onset date in (dd/mm/yyyy) format and specify the symptoms experienced.
13. For sexually transmitted diseases, provide specific treatment details, including the administration date, medication, dose, and duration of treatment.
14. Include detailed lab information relevant to the reported disease in the diagnostic testing section. You may attach a copy of lab results with Part 1 if necessary.
15. Fill in the name of the reporting physician or practice responsible for notifying public health.
16. If different from the reporter, provide the name of the healthcare provider treating the patient.
17. Once all sections are completed, ensure that you save any changes made to the form. You may choose to download or print a copy of the form or share it as required.

To ensure effective reporting and assist public health efforts, complete and submit the Confidential Communicable Disease Report Part 1 Fill In Form online today.