Get F M Cough 2012-2013 Influenza Report Form

Filling out the F M Cough 2012-2013 Influenza Report Form online is an important process for reporting suspected and confirmed cases of influenza. This guide provides clear, step-by-step instructions to assist you in accurately completing the form.

Follow the steps to successfully complete the influenza report form online.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Fill in the patient demographic information. Start with the report date, followed by the patient's last name, first name, date of birth, and street address. Continue with the city, zip code, and telephone numbers (home and work/mobile).
3. Indicate the date of symptom onset and medical record number. Check all positive tests for influenza, including options for Influenza A and B culture testing.
4. Provide additional patient details including sex, race, occupation or school, and the physician's name and phone number.
5. Specify the laboratory conducting the tests, the age of the patient, and the specimen collection date. If the source of the specimen is not nasopharynx, indicate accordingly.
6. If applicable, complete the hospitalized/ICU/fatal case section. Provide the hospital name, admission and discharge dates, and indicate if the patient was admitted to the intensive care unit or if the case was fatal.
7. Complete the clinical information section for ICU or fatal cases, including symptom onset date and the highest recorded fever. Document body measurements such as height and weight.
8. Check all underlying conditions that apply to the patient and indicate if any antiviral or antibiotic treatments were prescribed.
9. Report if the patient received a seasonal flu vaccine and document any medical complications encountered.
10. Fill in the reporter information section by including the reporter's name, facility name, and contact number. Specify the type of reporter such as DO/MD, RN, or other.
11. Review all entered information for accuracy. Save changes, download, print, or share the form as required. Finally, fax the completed report to 215-238-6947.

Start completing your influenza report form online today!