Follow the steps to accurately complete the form

1. Click the ‘Get Form’ button to obtain the form and open it in the designated online editor.
2. Begin with entering the patient information. Fill in the required fields such as the name (last and first), address, city or town, date of birth, county, age, sex, state, ethnicity, and phone number.
3. Select the race of the patient from the options provided and indicate if they are Hispanic or Non-Hispanic.
4. Provide additional details including occupation, pregnancy status, and whether the patient has been hospitalized. If hospitalized, include the facility name, admit date, and duration of stay.
5. Indicate if the patient traveled within 30 days before the onset of illness, supplying location and dates of travel if applicable.
6. In the disease information section, specify the disease or organism and attach any relevant laboratory data. Fill in the date of illness onset and indicate any signs or symptoms present.
7. Document any disease-specific immunizations received by the patient, along with treatment details including medication name, dose, and duration.
8. Answer questions regarding any underlying medical conditions and provide any relevant comments.
9. If applicable, complete the varicella-specific section by indicating rash presence, lesion details, and vaccination history.
10. Finish the hepatitis-specific section by checking any sexually transmitted risk factors and entering lab results for hepatitis A, B, and C.
11. Complete the healthcare provider reporting information, providing details on who is reporting, the report date, ordering provider, and facility information.
12. Once all required fields are completed, review your information for accuracy. Finally, save your changes, download, print, or share the completed form as needed.

Fill out the RI Infectious Disease Case Report Form online today to contribute to public health efforts.