Get Nj E-cigarette/vaping And Lung Injury Investigation Case Report Form 2019-2025

Filling out the NJ E-cigarette/Vaping And Lung Injury Investigation Case Report Form online is an essential step in reporting potential lung injuries related to e-cigarette use. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to fill out the form online effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient’s name and medical record number in the designated fields. Ensure this information is accurate as it is crucial for the investigation.
3. Input the patient's date of birth and contact information, including phone number and address. This information aids in reaching out for further details if necessary.
4. Document the facility name where the patient was treated and provide primary admission diagnosis alongside the admission date.
5. Fill out the contact information for the individual completing the form, including their name, phone number, email, and role at the facility.
6. Record the patient’s age and gender to maintain comprehensive demographic data.
7. In the inpatient admission section, clarify whether the patient was admitted to the hospital or ICU, and detail any relevant admission information, including the admitting provider and any previous facility visits for similar issues.
8. Collect and document information regarding the patient's vaping or e-cigarette use within the past 90 days, specifying products used and their availability for testing.
9. Indicate the status of the patient's hospitalization, including discharge details if applicable, along with the cause of death if the patient is deceased.
10. Provide relevant radiology findings, noting dates and results for chest X-rays and CT scans, and include any pertinent infectious disease evaluations.
11. Finally, use the general comments section for any additional notes that may aid in the investigation.

Complete the NJ E-cigarette/Vaping And Lung Injury Investigation Case Report Form online today.