Get Varicella Reporting Form Fax To (614) 525-8890 - Idrsinfo

Completing the Varicella Reporting Form is essential for accurately reporting cases of varicella, also known as chickenpox. This guide provides step-by-step instructions for filling out the form, ensuring that all necessary information is provided clearly and correctly.

Follow the steps to fill out the VARICELLA REPORTING FORM

1. Press the ‘Get Form’ button to access the Varicella Reporting Form and have it opened in your preferred document editor.
2. Begin by filling out the demographic information section. Provide the patient's first and last name, date of birth, current address, city, and zip code. Specify the patient's gender and race by selecting the appropriate options.
3. If applicable, fill out the parent or guardian's first and last name. Indicate the ethnicity of the patient by choosing from the listed categories.
4. Provide contact information, including phone numbers (home, work, and cell) to ensure you can be reached if necessary.
5. Move to the clinical information section. Indicate whether the patient has a rash by selecting 'Yes,' 'No,' or 'Unknown.' Next, assess the severity of varicella based on the number of lesions and provide the rash onset date.
6. Specify if the patient has received the Varicella vaccine and indicate the dose(s) received along with the dates of vaccination. Detail the locations of the rash on the body.
7. Indicate if the patient has a fever, and if lab testing was conducted, provide the specimen collection date.
8. Complete the reporting source section by selecting the appropriate source, whether from a physician’s office, school, lab, or preschool/childcare. Fill in the contact name, facility name, phone number, and fax number for follow-up.
9. Review all the information for accuracy. Once finalized, you can save changes, download, print, or share the completed form as needed.

Start filling out the Varicella Reporting Form online today to ensure timely and accurate reporting.