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. 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 NYC, borough unknown A Unknown ( ______) ______– ______ Unknown T 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 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 ______ 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

Amebiasis (Entamoeba histolytica only Ehrlichiosis, Human monocytic ehrlichiosis Herpes, Neonatal: see STD section, page 3 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.) ** Encephalitis HIV/AIDS. For assistance in reporting a case of select Typhoid/Paratyphoid Fever Anaplasmosis Jul.1–Oct. 31 consider and test for West Nile virus. HIV/AIDS, to receive the required New York State 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 Shigellosis ** arbovirus), report under the other disease. information, call (212) 442-3388. Animal Bites (please fill out animal bite information below) Smallpox * Exposure to rabies * Escherichia coli O157:H7 ** Influenza Check all that apply: Staph Enterotoxin B * Including a bite or other exposure (e.g, scratch) to any Escherichia coli (other) Shiga Toxin Producing ** Suspected novel viral strain with pandemic potential 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 Giardiasis ** any mammal exhibiting signs suggestive of rabies. Death in a child younger than 18 years of age Source: ______ Glanders * Animal Species: ______Kawasaki Syndrome MIC (μg/ml): ______Gonorrhea: see STD section, page 3 Breed: ______Granuloma Inguinale: see STD section, page 3 Legionellosis, Specify positive test: Streptococcus (Group A) Invasive only Color(s): ______ Culture Urine antigen Hantavirus * Specify Source: Blood CSF Unknown Date of Bite: ____ / ____ / ____ DFA Serology Other, Specify: ______ Hemolytic Uremic Syndrome Area of body bitten ______ Leprosy (Hansen’s Disease) Streptococcus (Group B) Invasive only Hemophilus influenzae, invasive only Activity at time of bite ______ Specify Source: Blood CSF Unknown Specimen Source: Leptospirosis Place of occurrence ______ Other, Specify: ______ Blood CSF Unknown Listeriosis Treatment given: ______ Other______ Lyme Disease Syphilis: see STD section, page 3 Rabies prophylaxis Yes No Specify Serotype: Erythema migrans present? HRIG Yes No Type B Not typeable Yes No Unknown Tetanus Not tested Unknown Rabies Vaccine Yes No Lymphocytic Choriomeningitis Virus Toxic shock syndrome, For staph only. Other______Animal Owned Stray Unknown For strep select Streptococcus (Group A). Animal’s owner (last name, first name): Lymphogranuloma Venereum: see STD section on Page 3 Trachoma ______ Transmissible Spongiform Encephalopathy 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: ______ Unknown ______Lab reference range: ______ Unknown Measles * Trichinosis: Caused by bacterium Trichinella Telephone Number: Melioidosis * spiralis. (Trichomoniasis, caused by Trichomonas vaginalis, need not be reported.) ( ______) ______– ______ Hepatitis A */** Meningitis, Aseptic/Viral Tuberculosis: see TB section on page 4 Anthrax * Total Ab to Hepatitis A is NOT reportable Jul.1–Oct. 31 consider and test for West Nile virus. Arboviral Infections * IgM anti-HAV: Pos Neg Unknown If due to another reportable disease (e.g. Lyme, West Nile, Tularemia * arbovirus), report under the other disease. Specify which virus: ______ Typhoid /Paratyphoid Fever ** Hepatitis B If Dengue, West Nile or Yellow Fever, report as such. Meningitis, other bacterial Report at least one positive hepatitis B test result: Attach copies of diagnostic laboratory results if available. Specify Organism: ______Vaccinia disease (adverse events associated with Total Ab to Hepatitis B is NOT reportable smallpox vaccination) * Babesiosis Babesiosis can be transmitted through blood products. If IgM anti-HBc Pos Neg Unknown Meningococcal Disease, Invasive * 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 Viral Hemorrhagic Fever * suspected/confirmed cases immediately.* Antigen test from CSF Gram stain ners in the past year (Check only one) Botulism * Other______ West Nile Virus * Attach copies of diagnostic labora- Males only Females only Foodborne Wound Infant tory results if available Males and Females Unknown Brucellosis * Monkeypox * Window Falls. 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 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 Plague * Cholera */** Cases in pregnant women must be reported on the IMM5 or via Report. For assistance call 1-866-NYC-DOH1 Creutzfeld-Jakob Disease: see Transmissible Reporting Central. For information call 718-520-8245. Poisoning: see Poisoning section, page 3 Spongiform Encephalopathy Polio * Yellow Fever * Attach copies of diagnostic labora- Hepatitis C Cryptosporidiosis ** tory results if available Check all that apply: Psittacosis Cyclospora ** Yersiniosis ** non-plague EIA with high s/co value: ______ Q Fever * Dengue RIBA pos. HCV Nucleic Acid (e.g.PCR) pos Rabies * Attach copies of diagnostic laboratory results if available. Is this an acute/new infection? Yes No Unk Ricin * Drowning Hepatitis D Respiratory impairment from submersion/immersion in liquid. Rickettsialpox Hepatitis E Drowning Location: ______ Rocky Mountain Spotted Fever Hepatitis other/Unspecified Outcome: Death Morbidity No Morbidity Rubella For hepatitis D, E, and other/unspecified, please describe in for an IgM positive case in pregnant women* Diphtheria * comments box on Page 1. Rubella, Congenital Syndome

Page 2 * Report suspected/confirmed cases immediately 1-866-NYC-DOH1, after hours 1-212-764-7667; Report all other results within 24 hours. ** Please complete Risk Groups section on front of form. Patient Last Name First Name Medical Record Number

POISONINGS MODE OF EXPOSURE TYPE QUANTITY REASON Intentional SYMPTOM ASSESSMENT (Check all that apply) Ingestion Milliliter (mL) ______Unintentional Suspected suicide Lead For persons aged 16 and older indicate: None Electrolyte abnormalities Misuse Ocular Mouthful ______General Nausea/vomiting/diarrhea Cough/shortness of breath Employer ______ Environmental Abuse Lethargic/stupor/coma Occular irritation Dermal Sip ______ Therapeutic Unknown Employer Phone: Inhalation Misuse Agitated Skin irritation ( _____ ) _____ – ______ Tablespoon ______ Bite/sting Other Hypertensive Unknown Aural Tab/pill/cap ______ Food poisoning Contamination/ Hypotensive Other Arsenic Cadmium Carbon Monoxide* tampering Bite Occupational Tachycardia Mercury Pesticide Taste/lick/drop______ Malicious ______ Sting Dietary Brachycardia Withdrawal IV Other ______ Teaspoon ______ Consumer product Seizure Unknown Other ______ Unknown Adverse reaction Drug PROVIDER TREATMENT SPECIMEN SOURCE TIME OF EXPOSURE Food No therapy required Irrigated eye Capillary Venous Urine Laboratory Accession Number ______: ______Other Unknown Oral fluids Oxygen Other ______ ______AM PM Emesis Naxolone Date Collected VITAL SIGNS Lavage 50% Dextrose/Thiamine Activated charcoal Alkalinize urine ____ / ____ / ______Results (units) ______Body Weight ______Pupils: Resp: ______ Cathartic N-acetylcysteine (Mucromyst) Purpose of test Pounds Kilograms Dilated Chelation Other: Date Analyzed Initial Repeat Temp: ______F C Constricted Insect sting mgmt. ______/ ____ / ______ Follow-up BP: ______/ ______Pulse: ______SEXUALLY TRANSMITTED DISEASES Specimen collection date ___ / ___ / ____ Treatment for infant ______Syphilis Test Types. Check all that apply FOR ALL STD REPORTS Treatment ______Treatment date ___ / ___ / ____ Unknown 1. Serologic tests for syphilis As of the date of this report, A. Non-treponemal Test Treatment date ___ / ___ / _____ Unknown Mother’s Name: ______Were any of this patient’s sex partners notified of RPR possible exposure to a sexually transmitted disease? Gonorrhea (GC) Specify specimen source: Mother’s DOB: ____ / ____ / ______ Reactive Non-reactive Yes, our office notified the partner(s) Endocervical Urethral Anorectal Titer ______Yes, the patient was asked to notify partner(s) Oropharyngeal Urine Lymphogranuloma Venereum No Unknown VDRL Other ______Clinical Presentation (Check all that apply): Did you provide treatment for any of this patient’s Reactive Non-reactive Proctitis Lymphadenopathy Skin lesion sex partners? Specify test type: Titer ______ Buboe Yes, I gave extra medication/prescription for Culture Nucleic acid amplification Other ______Specimen collection date ___ / ___ / ____ the sex partner(s) Nucleic acid hybridization If yes, for how many sex partners was medication/ Specimen collection date ___ / ___ / ____ B. Treponemal Test Other: ______prescription provided? ______ TP-PA/MHA-TP Reactive Non-reactive Treatment ______Yes, I saw the sex partner(s) in my office Specimen collection date ___ / ___ / ____ FTA Reactive Non-reactive No Unknown Treatment date ___ / ___ / _____ Unknown Treatment ______ Treponemal IgG Reactive Non-reactive

For all sexually transmitted diseases, indicate Treatment date ___ / ___ / _____ Unknown Syphilis Specimen collection date ___ / ___ / ____ sexual partners in past year (Check only one) Males only Females only Stage: 2. Cerebrospinal fluid tests Granuloma Inguinale Specify specimen source: Males and Females Unknown Congenital CSF VDRL Penile Vaginal Endocervical Primary (chancre present) check all that apply Reactive Non-reactive Anorectal Oropharyngeal Penile Vaginal Endocervical Chancroid Specify specimen source: Other ______ Anorectal Oropharyngeal CSF FTA Penile Vaginal Endocervical Specimen collection date ___ / ___ / ____ Other ______Reactive Non-reactive Anorectal Oropharyngeal Treatment ______Secondary Other Test: ______ Alopecia Condylomata Other ______ Treatment date ___ / ___ / _____ Unknown Mucous patches Rash Result: ______Specimen collection date ___ / ___ / ____ Early Latent Herpes, Neonatal (no symptoms, infection ≤ 1 year duration) Specimen collection date ___ / ___ / ____ Treatment ______Herpes simplex virus infection in infants aged 60 days or less. Late Latent Elevated CSF protein Treatment date ___ / ___ / _____ Unknown Clinical dx (no symptoms, infection of > 1 year duration) Yes No Tertiary (gumma or cardiovascular) Lab confirmed dx: Culture PCR Elevated CSF leukocytes Chlamydia (CT) Specify specimen source: Antigen detection Serologic Tzanck Neurologic symptoms present? Yes No Endocervical Urethral Anorectal Herpes type: Type 1 Type 2 Not typed Yes No Unknown Specimen collection date ___ / ___ / ____ Oropharyngeal Urine Clinical Syndrome (check all that apply): Treatment : 3. Organism visualization Other ______ Skin, eye, mucous membrane infection List Medication and Dosage: Specify test type: CNS involvement Disseminated disease Darkfield ______ Positive Negative Culture Nucleic acid amplification Herpes lesions present? Treatment date ___ / ___ / ___ Unknown Other test: ______ Nucleic acid hybridization Yes, anatomic site ______ EIA DFA No Unknown Result: ______ Other: ______Specimen collection date ___ / ___ / ____ Specimen collection date ___ / ___ / ____

* Report suspected/confirmed cases immediately 1-866-NYC-DOH1, after hours 1-212-764-7667; Report all other results within 24 hours. ** Please complete Risk Groups section on front of form. Page 3 Patient Last Name First Name Medical Record Number

TUBERCULOSIS Please complete Risk Groups section on front of form. Tuberculosis Check all that apply AFB Smear TB Screening Test QuantiFERON® TB-Gold in tube (QFT-GIT) Primary disease site: Other sites: Positive Test Type: Positive Negative Indeterminate or Invalid Pulmonary Pulmonary Smear Grade: suspicious History of Positive TST Lymphatic Lymphatic 1+ rare 2+ few T-Spot.TB TST, Size ______mm Bone/Joint Bone/Joint Positive Negative 3+ moderate 4+ numerous Soft tissue/Muscles Soft tissue/Muscles Positive Negative Borderline (equivocal) Peritoneal Peritoneal Negative Pending Date Implanted Indeterminate or Invalid Meningeal Meningeal Not Done Unknown ____ / ____ / ______Date blood drawn Genitourinary Genitourinary M. tb Culture Gastronintestinal Gastronintestinal ____ / ____ / ______Positive Negative ® QuantiFERON TB-Gold (QFT-G) Other: Other: Pending Contaminated Positive Negative Other: ______ Not Done Unknown Indeterminate or Invalid Not done Unknown Laboratory Results: Nucleic Acid Amplification (NAA) Specimen Number ______Test Type: Unknown MTD Amplicor Not Done Unknown Specimen Source: Other: ______Treatment Test Result: Sputum On Anti-TB Medications Yes No Unknown Tracheal aspirate Positive Negative Pending Please complete for each medication: Dose Start Date Bronchial fluid/Broncho-alveolar lavage Not Done Unknown Lymph node Pathology consistent with TB Isoniazid (INH) . . ____ / ____ / ______ Lung tissue Positive Negative Rifampin (RIF) . . ____ / ____ / ______ Pleural fluid Not Done Unknown Pyrazinamide (PZA) . ____ / ____ / ______ Pleura Pathology findings: ______Ethambutol (EMB) . . ____ / ____ / ______ Blood ______ Other 1 . . ____ / ____ / ______Urine ______ Other: ______Other 2 . . ____ / ____ / ______Chest X-Ray ___ / ___ / _____ Other 3 . . ____ / ____ / ______ Collection date ___ / ___ / _____ Unknown Normal Abnormal Isolation: Yes No Unknown Testing Laboratory:______Miliary Non-Cavitary Unknown Cavitary Consistent with TB Other Medical Problems/Other Pertinent Information: Not consistent with TB CT Scan / MRI ___ / ___ / _____ Normal Abnormal Miliary Non-Cavitary Cavitary Consistent with TB Not consistent with TB

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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/health/nycmed

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