Confidential Communicable Disease Report- Dhhs 2124

NC Electronic Disease Surveillance System NC EDSS EVENT ID# ______North Carolina Department of Health and Human Services ATTENTION HEALTH CARE PROVIDERS: Division of Public Health • Epidemiology Section Please report relevant clinical findings about this Communicable Disease Branch disease event to the local health department.

Confidential Communicable Disease Report—Part 1 NAME OF DISEASE / CONDITION

Patient’s Last Name First Middle Suffix Maiden/Other Alias Birthdate (mm/dd/yyyy) / / Patient’s Last Name First Middle Suffix Maiden/Other Alias SSN

Birthdate (mm/dd/yyyy) Sex Parent or Guardian (of minors) Medical Record Number Instructions for completing the Communicable M FDisease Trans. Questions? Concerns? Contact the NC EDSS Helpdesk: Report Form can be found in the NC Public Health Phone: ...... (919) 715-5548 Patient’sCommunicable Street Address Disease Manual online at: City StateToll Free:ZIP ...... (877)County Phone 625-9259 www.epi.state.nc.us/epi/gcdc/manual/toc.html. Email: ...... [email protected](_____) _____-______Age Age Type Race (check all that apply): Ethnic Origin Was patient hospitalized for Did patient die from Is the patient Years White Asian Hispanic NC EDSS Verify if lab results for this event are in NC thisEDSS. disease? If not (>24 present, hours) enterthis results. disease? pregnant? Months Black/African American Other Non-Hispanic LAB RESULTS Yes No Yes No Yes No Weeks American Indian/Alaska Native Unknown Days Native Hawaiian or Pacific Islander Date / /

Patient is associated with (check all that apply): In what geographic location was the patient MOST LIKELY exposed? Child Care (child, household contact, Correctional Facility (inmate or worker) In patient’s county of residence or worker in child care) Long Term Care Facility (resident or worker) Outside county, but within NC - County: ______School (student or worker) Military (active military, dependent, Out of state - State/Territory:______College/University (student or worker) or recent retiree) Out of USA - Country:______Food Service (food worker) Travel (outside continental United States Unknown Health Care (health care worker) in last 30 days) CLINICAL INFORMATION Is/was patient symptomatic for If a sexually transmitted disease, give specific treatment details this disease?...... Y N U 1. Date patient treated:(mm/dd/yyyy)______2. Date patient treated:(mm/dd/yyyy)______If yes, symptom onset date (mm/dd/yyyy): / / SPECIFY SYMPTOMS: Medication______Medication______Dosage______Dosage______Duration______Duration______

DIAGNOSTIC TESTING Provide lab information below and fax copy of lab results and other pertinent records to local health department.

Specimen Specimen # Specimen Type of Test Test Description (comments) Result Date Lab Name—City/State Date Source Result(s) / / / / / / / / / / / /

Reporting Physician/Practice: Health Care Provider for this disease (if not reporting physician): ______Contact Person/Title:______Contact Person/Title:______Phone: (_____) _____–______Fax:(_____) _____–______Phone: (______) ______– ______Fax: (______) ______–______

LOCAL HEALTH DEPARTMENT USE ONLY Initial Date of Report to Public Health:____/____/______Is the patient part of an outbreak of this disease? Yes No Initial Source of Report to Public Health: Outbreak setting: Household/Community (specify index case):______Health Care Provider (specify): Restaurant/Retail Assisted living facility Hospital

Private clinic/practice Child Care Adult day care Health Department Long term care School Name of facility______Correctional facility Healthcare setting Prison Address of facility______Laboratory Adult care home ______Other

DHHS 2124 (Revised January 2016) EPIDEMIOLOGY Diseases and Conditions Reportable in North Carolina

Physicians must report these diseases and conditions to the county local health department, according to the North Carolina Administrative Code: 10A NCAC 41A.0101 Reportable Diseases and Conditions (see below). Contact information for local health departments can be accessed at www.ncalhd.org/directors. If you are unable to contact your local health department, call the 24/7 pager for N.C. Communicable Disease Branch (919) 733-3419. For diseases and conditions required to be reported within 24 hours, the initial report shall be made by telephone to the local health department, and the written disease report be made within 7 days. The reporting rules and disease report forms can be accessed at: http://epi.publichealth.nc.gov/cd/report.html

Diseases in BOLD ITALICS should be reported immediately to local health department. Reportable to Local Health Department Within Reportable to Local Health Department Within 24 Hours 7 Days DISEASE/CONDITION DISEASE/CONDITION A-G A-G ANTHRAX ...... Brucellosis ...... BOTULISM, FOODBORNE ...... Chlamydial infection—laboratory confirmed ...... BOTULISM, INTESTINAL (INFANT) ...... Creutzfeldt-Jakob Disease ...... BOTULISM, WOUND ...... Dengue ...... Campylobacter infection ...... Ehrlichiosis, HGA (human granulocytic anaplasmosis) ...... Chancroid ...... Ehrlichiosis, HME (human monocytic or e. chaffeensis) ...... Chikungunya ...... Ehrlichiosis, unspecified ...... Cholera ...... Encephalitis, arboviral, WNV ...... Cryptosporidiosis ...... Encephalitis, arboviral, LAC ...... Cyclosporiasis ...... Encephalitis, arboviral, EEE ...... Diphtheria ...... Encephalitis, arboviral, other ...... E. coli infection, shiga toxin-producing ...... H-N Foodborne disease: Clostridium perfringens ...... Hantavirus infection ...... Foodborne: staphylococcal...... Hepatitis B, carriage ...... Foodborne disease: other/unknown ...... Hepatitis B, perinatally acquired ...... Foodborne poisoning: ciguatera ...... Hepatitis C, acute ...... Foodborne poisoning: mushroom ...... Legionellosis ...... Foodborne poisoning: scombroid fish...... Leprosy ...... Gonorrhea ...... Leptospirosis ...... Granuloma inguinale ...... Lyme disease ...... H-N Lymphogranuloma venereum ...... Haemophilus influenzae, Malaria ...... invasive disease ...... Meningitis, pneumococcal ...... Hemolytic-uremic syndrome (HUS) ...... Mumps ...... HEMORRHAGIC FEVER VIRUS Non-gonococcal urethritis ...... INFECTION ...... O-Z Hepatitis A...... Pelvic inflammatory disease...... Hepatitis B, acute ...... Psittacosis ...... HIV/AIDS Q fever ...... HIV...... Rocky Mountain Spotted Fever ...... AIDS ...... Rubella, congenital syndrome ...... Influenza virus infection causing death ...... Streptococcal infection, Group A, invasive ...... Listeriosis...... Tetanus ...... Measles (rubeola) ...... Toxic shock syndrome, non-streptococcal ...... Meningococcal disease, invasive ...... Toxic shock syndrome, streptococcal ...... Middle East respiratory syndrome (MERS) ...... Trichinosis ...... Monkeypox ...... Typhoid, carriage (Salmonella typhi) ...... NOVEL INFLUENZA VIRUS INFECTION ...... Yellow fever ...... O-U Ophthalmia neonatorum ...... Pertussis (Whooping Cough)...... You may be contacted by the local health department PLAGUE ...... for additional information about this case. Medical Poliomyelitis, paralytic ...... record information relevant to the investigation and/or Rabies, human ...... Rubella ...... control of a communicable disease is exempt from the Salmonellosis ...... HIPAA Privacy Rule (see 45 CFR 164.512(a) ) and is S. aureus with reduced susceptibility to vancomycin ...... permitted as an exception to confidentiality of records in SARS coronavirus infection ...... Shigellosis ...... NC State Law GS § 130 A-130. SMALLPOX ...... Syphilis North Carolina General Statute: primary...... §130A-135. Physicians to report. secondary ...... A physician licensed to practice medicine who has reason to suspect that a early latent ...... person about whom the physician has been consulted professionally has a communicable disease or communicable condition declared by the : late latent ...... late with clinical manifestations ...... Commission to be reported, shall report information required by the congenital ...... Commission to the local health director of the county or district in which Tuberculosis ...... the physician is consulted. TULAREMIA ...... Typhoid Fever, acute ...... North Carolina Administrative Code: 10A NCAC 41A.0101 Reportable Diseases and Conditions V-Z (a) The following named diseases and conditions are declared to be Vaccinia ...... dangerous to the public health and are hereby made reportable within the Vibrio infection, other than cholera & vulnificus ...... time period specified after the disease or condition is reasonably Vibrio vulnificus ...... suspected to exist: Zika......

DHHS 2124 (Revised January 2016) EPIDEMIOLOGY