Get In Form 43823 2016-2025

Filling out the IN Form 43823 online is essential for reporting communicable diseases accurately. This guide provides clear, step-by-step instructions to help users complete the form effectively, ensuring that all necessary information is collected.

Follow the steps to complete your form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Enter your name in the designated fields, including last, first, and middle initial. If this form is for a child, include the parent’s name.
3. Fill in your address, including the street number and name, city, zip code, and county.
4. Indicate your occupation if applicable. There are options such as health care worker, food service, and school or daycare staff. This step is optional for sexually transmitted diseases.
5. Provide your date of birth in the specified format (MM/DD/YYYY) and select your sex as either male or female.
6. Choose your race and indicate your ethnicity from the provided options.
7. If applicable, include the name of your workplace or school/daycare. Specify if you are pregnant.
8. Under the clinical section, provide the date of diagnosis, describe the symptoms, and note the onset date.
9. Indicate if the individual is deceased or hospitalized, and fill in the corresponding hospital details if necessary.
10. In the laboratory section, document the test performed, its result, the specimen collection date, and the specimen source.
11. For treatment, detail the name of the antibiotic used, the dosage, and the treatment date.
12. Fill in the provider details, including the physician's name and who is reporting the incident, along with contact information.
13. Record the date of report and the date of first notification. Include the name of the investigator.
14. Complete any additional required information for local health department use.
15. Once all sections are thoroughly filled out, you can save your changes, download, print, or share the completed form for submission.

Complete your IN Form 43823 online today to ensure timely reporting of communicable diseases.