NYS DOH STD Reporting Form
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To order more copies of this form call the Provider Access Line: 1-866-NYC-DOH1 NYC Department of Health & Mental Hygiene Universal Reporting Form PHA No. Form PD-16 (9/09) Mail completed form to: NYC Dept. of Health & Mental Hygiene; 125 Worth Street, Room 315, CN-6; New York, NY 10013 • Or report online: www.nyc.gov/nycmed P Patient Last Name First Name Middle Name DATE OF REPORT A T Patient AKA: Last Name AKA: First Name M.I . I ____ / ____ / ____ E Date of Birth Age Country of Birth Soc.Sec.No. N T ____ / ____ / ________ If patient is a child, Guardian Last Name Guardian First Name M.I. Ⅺ Homeless I Borough: Manhattan N Patient Home Address Apt. No. Zip Code Bronx F Unknown Brooklyn O Home Telephone Number Medical Record Number ( _______ ) ________ – _____________ Queens R Unknown M Staten Island Other Telephone Number Medicaid Number Ⅺ NYC, borough unknown A Unknown ( _______ ) ________ – _____________ Unknown T Ⅺ I Sex Race (Check all that apply) Ethnicity Hispanic Please report non-NYC Not NYC (Specify City/State) Male Transexual Asian White American Indian/Alaska Native Unknown (Check one) Non-Hispanic residents to the appropriate ________________, _____ O N Female Unknown Black Other race Native Hawaiian/Pacific Islander Unknown health jurisdiction Ⅺ Unknown Admitted to hospital? Admission Date Is patient alive? If no, date of death Unknown Is patient pregnant? If yes, due date Yes No ____ / ____ / ________ Unknown Yes No Yes No Unknown Discharge Date Unknown ____ / ____ / ________ Unknown Unknown _____ / _____ / ________ Unknown ____ / ____ / ______ DATE OF DIAGNOSIS Risk Groups for Disease Exposure and/or Transmission Unknown ____ / ____ / _______ Patient works in: Childcare Food service Health care Nursing home Other _________________________________________ Ⅺ DATE OF ILLNESS ONSET Attends/resides in: Nursing home Day Care/Group baby-sit Homeless shelter Correctional facility School Hospital Other _____________ Unknown ____ / ____ / _______ Foreign travel: Countries ____________________________________________________ Date returned to U.S. __ __ / __ __ / __ __ Name of Person Reporting Disease Phone REPORTER INFORMATION Number ( _______ ) ________ – _____________ Facility of Person Reporting Disease PFI Code Street Address City State Zip Code Name of Hospital/Healthcare Facility PFI Code Phone Unknown ( _______ ) ________ – _____________ Street Address City State Zip Code Name of Testing Laboratory PFI Code Phone Unknown Unknown Unknown ( _______ ) ________ – _____________ Street Address City State Zip Code Unknown Unknown Unknown Unknown Name of Physician Phone Unknown Unknown ( _______ ) ________ – _____________ Street Address City State Zip Code Unknown Unknown Unknown Unknown Call DOHMH if there is an outbreak or suspected outbreak of any disease or condition, of known or unknown etiology occurring in three or more persons or any unusual manifestation of a disease in an individual. Call Provider Access Line 1-866-NYC-DOH1; after hours, call Poison Control Center 1-212-Poisons (764-7667) Comments (Additional space on Page 4) Page 1 Patient Last Name First Name Medical Record Number DISEASE WITH SPECIAL INSTRUCTIONS Ⅺ Amebiasis (Entamoeba histolytica only Ⅺ Ehrlichiosis, Human monocytic ehrlichiosis Herpes, Neonatal: see STD section, page 3 Ⅺ Salmonellosis ** Serogroup: _______ or cases in which E. histolytica cannot be If human granulocytic anaplasmosis report as anaplasmosis. If due to Salmonella typhi or paratyphi, distinguished from Entamoeba dispar.) ** Ⅺ Encephalitis HIV/AIDS. For assistance in reporting a case of select Typhoid/Paratyphoid Fever Ⅺ Anaplasmosis Jul.1–Oct. 31 consider and test for West Nile virus. HIV/AIDS, to receive the required New York State Ⅺ SARS (Severe Acute Respiratory Syndrome) * Formerly human granulocytic ehrlichiosis If due to another reportable disease (e.g. Lyme, West Nile, Provider Report Forms (PRF), or to obtain more Ⅺ Shigellosis ** arbovirus), report under the other disease. information, call (212) 442-3388. Ⅺ Animal Bites (please fill out animal bite information below) Ⅺ Smallpox * ࠗ Exposure to rabies * Ⅺ Escherichia coli O157:H7 ** Ⅺ Influenza Check all that apply: Ⅺ Staph Enterotoxin B * Including a bite or other exposure (e.g, scratch) to any Ⅺ Escherichia coli (other) Shiga Toxin Producing ** ࠗ Suspected novel viral strain with pandemic potential Ⅺ Staphylococcus aureus, vancomycin intermediate animal confirmed to have rabies, or from any rabies (e.g. H5) * and resistant * vector species (raccoon, bat, skunk, fox or coyote), or Ⅺ Giardiasis ** any mammal exhibiting signs suggestive of rabies. ࠗ Death in a child younger than 18 years of age Source: ____________________ Ⅺ Glanders * Ⅺ Animal Species: _____________________ Kawasaki Syndrome MIC (μg/ml): _________________ Gonorrhea: see STD section, page 3 Breed: __________________________ Granuloma Inguinale: see STD section, page 3 Ⅺ Legionellosis, Specify positive test: Ⅺ Streptococcus (Group A) Invasive only Color(s): _________________________ ࠗ Culture ࠗ Urine antigen ࠗ ࠗ ࠗ Ⅺ Hantavirus * Specify Source: Blood CSF Unknown Date of Bite: ____ / ____ / ____ ࠗ DFA ࠗ Serology ࠗ Other, Specify: ___________________ Ⅺ Hemolytic Uremic Syndrome Area of body bitten __________________ Ⅺ Leprosy (Hansen’s Disease) Ⅺ Streptococcus (Group B) Invasive only Ⅺ Hemophilus influenzae, invasive only Activity at time of bite ________________ Ⅺ Specify Source: ࠗ Blood ࠗ CSF ࠗ Unknown Specimen Source: Leptospirosis Place of occurrence __________________ ࠗ Other, Specify: ___________________ ࠗ Blood ࠗ CSF ࠗ Unknown Ⅺ Listeriosis Treatment given: ___________________ ࠗ Other_______________________ Ⅺ Lyme Disease Syphilis: see STD section, page 3 Rabies prophylaxis ࠗ Yes ࠗ No Specify Serotype: Erythema migrans present? ࠗ ࠗ ࠗ ࠗ ࠗ Ⅺ HRIG ࠗ Yes ࠗ No Type B Not typeable Yes No Unknown Tetanus ࠗ ࠗ ࠗ ࠗ Not tested Unknown Ⅺ Rabies Vaccine Yes No Ⅺ Lymphocytic Choriomeningitis Virus Toxic shock syndrome, For staph only. ࠗ Other_______________________ Animal ࠗ Owned ࠗ Stray ࠗ Unknown For strep select Streptococcus (Group A). Ⅺ Animal’s owner (last name, first name): Lymphogranuloma Venereum: see STD section on Page 3 Trachoma ______________________________ Ⅺ Transmissible Spongiform Encephalopathy Ⅺ Address (Street, Apt.): FOR ALL HEPATITIS REPORTS: Malaria ** Select at least one of the following: Creutzfeld-Jakob Disease and variants ࠗ falciparum ࠗ vivax ࠗ malariae Testing done: ______________________ ______________________________ Jaundice ࠗ Yes ࠗ No ࠗ Unknown ࠗ ovale ࠗ undetermined (e.g. 14-3-3 on CSF, brain biopsy, autopsy, EEG/MRI) Boro/City, State, Zip: ALT (SGPT) value: _____________⅜ Unknown Ⅺ ______________________________ Lab reference range: ___________⅜ Unknown Measles * Ⅺ Trichinosis: Caused by bacterium Trichinella Ⅺ Telephone Number: Melioidosis * spiralis. (Trichomoniasis, caused by Trichomonas vaginalis, need not be reported.) ( ______ ) ______ – _____________ Ⅺ Hepatitis A */** Ⅺ Meningitis, Aseptic/Viral Tuberculosis: see TB section on page 4 Ⅺ Anthrax * Total Ab to Hepatitis A is NOT reportable Jul.1–Oct. 31 consider and test for West Nile virus. Ⅺ Arboviral Infections * IgM anti-HAV: ࠗ Pos ࠗ Neg ࠗ Unknown If due to another reportable disease (e.g. Lyme, West Nile, Ⅺ Tularemia * arbovirus), report under the other disease. Specify which virus: __________________ Ⅺ Typhoid /Paratyphoid Fever ** Ⅺ Hepatitis B If Dengue, West Nile or Yellow Fever, report as such. Ⅺ Meningitis, other bacterial Report at least one positive hepatitis B test result: Ⅺ Attach copies of diagnostic laboratory results if available. Specify Organism: ___________________ Vaccinia disease (adverse events associated with Ⅺ Total Ab to Hepatitis B is NOT reportable smallpox vaccination) * Babesiosis Ⅺ Babesiosis can be transmitted through blood products. If IgM anti-HBc ࠗ Pos ࠗ Neg ࠗ Unknown Meningococcal Disease, Invasive * Ⅺ Vibrio spp. * patient has a history of receiving blood transfusion or If positive, describe symptoms and risks in Test type/Specimen source: Specify species: ____________________ donating blood within 3 months of onset of illness, report ࠗ ࠗ comments box on page 1 and indicate sexual part- Blood culture CSF Culture Ⅺ Viral Hemorrhagic Fever * suspected/confirmed cases immediately.* ࠗ Antigen test from CSF ࠗ Gram stain Ⅺ ners in the past year (Check only one) Botulism * ࠗ Other________________________ Ⅺ West Nile Virus * Attach copies of diagnostic labora- ࠗ Males only ࠗ Females only ࠗ Foodborne ࠗ Wound ࠗ Infant tory results if available ࠗ Males and Females ࠗ Unknown Ⅺ Brucellosis * Ⅺ Monkeypox * ࠗ ࠗ ࠗ Ⅺ Window Falls. Ⅺ Campylobacteriosis ** HBsAg: Pos Neg Unknown Mumps HBeAg: ࠗ Pos ࠗ Neg ࠗ Unknown Falls from windows of buildings with three or more Chancroid: see STD section, page 3 Ⅺ apartments, by children aged ten years and younger, HBV Nucleic Acid: ࠗ Pos ࠗ Neg ࠗ Unknown Pertussis for hospitalized cases* Chlamydia: see STD section, page 3 report on yellow Child Window Fall Notification Ⅺ Ⅺ Plague * Cholera */** Cases in pregnant women must be reported on the IMM5 or via Report. For assistance call 1-866-NYC-DOH1 Ⅺ Creutzfeld-Jakob Disease: see Transmissible Reporting Central. For information call 718-520-8245. Poisoning: see Poisoning section, page 3 Spongiform Encephalopathy Ⅺ Polio * Ⅺ Yellow Fever * Attach copies of diagnostic labora- Ⅺ Hepatitis C Ⅺ Cryptosporidiosis ** Ⅺ tory results if available Check all that apply: Psittacosis Ⅺ Cyclospora ** Ⅺ Yersiniosis **