Get Wa Doh 210-041 2022-2025

The WA DOH 210-041 form is essential for reporting cases of pertussis. This guide offers comprehensive instructions to help users accurately complete the form online, ensuring all necessary details are provided for effective public health response.

Follow the steps to complete the WA DOH 210-041 form online.

1. Click ‘Get Form’ button to access the WA DOH 210-041 form and open it for completion.
2. Begin by entering the case name (last, first) and the birth date in the specified format.
3. Indicate the age at symptom onset by filling in the years and months.
4. Provide any alternate names if applicable.
5. Fill in the information regarding pertussis, including phone number and address type (home, mailing, other).
6. Complete the demographic section, including the email and residence details.
7. In the administrative section, indicate if there is an investigator, the LHJ case ID, and the LHJ notification date.
8. Classify the case status as confirmed, investigation in progress, or other applicable status.
9. Document the report source, including the reporter organization and name.
10. Provide demographic information, including sex at birth, ethnicity, race, and preferred language.
11. Complete the employment and school section, indicating if the individual is employed or in school.
12. Fill in the communications section with details of the primary healthcare provider and any alternate contacts.
13. Document the clinical information regarding symptoms, illness duration, and diagnosis.
14. Provide vaccination history and hospitalization details if applicable.
15. Complete the risk and exposure section regarding contact history and public health issues.
16. Submit all components and ensure that all required fields are completed appropriately.
17. After finishing, you can save changes, download, print, or share the completed form.

Start filling out your WA DOH 210-041 form online today to ensure accurate reporting!