Get Dhhs 2124 2020-2025

The DHHS 2124 form is a vital document for reporting communicable diseases in North Carolina. This guide offers step-by-step instructions to help users accurately complete the form online, ensuring proper communication with health officials.

Follow the steps to fill out the DHHS 2124 form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the NC EDSS Event ID number in the designated field at the top of the form. This is essential for tracking the disease event.
3. In the NAME OF DISEASE/CONDITION section, specify the disease or condition being reported.
4. Fill out the patient's personal information, including last name, first name, middle name, and other identifiers like alias and medical record number.
5. Indicate the patient's sex, birthdate, and age type. Choose the appropriate age type from years, months, weeks, or days.
6. Complete the race and ethnic origin sections by checking all applicable options, and provide the patient's street address, city, state, and ZIP code.
7. Answer whether the patient was hospitalized for the disease, as well as if they died from it. Include the hospitalization date if applicable.
8. Indicate if the patient is pregnant and provide the geographic location of possible exposure to the disease.
9. Provide clinical information by indicating whether the patient is symptomatic. If yes, specify symptoms and their onset date.
10. If the disease is sexually transmitted, fill in treatment details, including dates, medications, dosages, and duration of treatment.
11. Document diagnostic testing information. Include lab details, specimen information, test type, results, and the date of those results.
12. Complete the LOCAL HEALTH DEPARTMENT USE ONLY section with the initial date of the report and the source of the report.
13. Finally, review all entries for accuracy, then save your changes. Once satisfied, download or print the completed form for your records, or share it as needed.

Ensure accurate reporting and complete the DHHS 2124 form online today.