Get Chikungunya Case Report Form - Testyourwell.nc.gov

Completing the Chikungunya Case Report Form is essential for the timely reporting and tracking of Chikungunya cases. This guide provides clear, step-by-step instructions to assist you in filling out the form accurately and efficiently.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the Chikungunya Case Report Form and open it in your editor.
2. Fill in the State Case Number and Date of Report at the top of the form.
3. Provide the patient’s demographics by entering their name, date of birth, sex, ethnicity, race, and residency status in North Carolina.
4. Complete the Patient Address section with the full address, city, county, state, and phone number.
5. In the Clinical section, indicate the onset of illness and date of first consultation, followed by documenting fever and other symptoms experienced by the patient.
6. If applicable, indicate whether the patient visited the Emergency Department, was hospitalized, or died from this illness, along with relevant hospital and visit dates.
7. In the Laboratory section, note whether the test results are pending, and fill in details for Chikungunya and other tests, including specimen collection dates and results.
8. Provide travel history, including the exposure period and places visited within the two weeks prior to the onset of illness.
9. Complete the Reporting Physician/Agency section by entering the submitter’s name, title, reporting practice details, and contact information.
10. If submitting for DPH/local health department use, complete the relevant dates and notes section.
11. After reviewing the form, save your changes. You can choose to download, print, or share the completed form.

Complete your Chikungunya Case Report Form online today to ensure accurate reporting.