New York City Department of Health and Mental Hygiene Universal Reporting Form

To report an immediately notifiable disease or condition, an outbreak among three or more persons or an unusual manifestation of any disease or condition, or any newly apparent or emerging disease or syndrome, call the Provider Access Line at 866-692-3641. Diseases and conditions in green and marked with * are immediately notifable; those marked with † are immediately notifiable if case meets the risk group criteria on page 2. Report by calling 866-692-3641. For all other diseases and conditions, report using Reporting Central online via NYCMED at www.nyc.gov/health/nycmed, mail this form to the NYC Department of Health and Mental Hygiene, 42-09 28th Street, CN-22, Long Island City, NY 11101, or call 866-692-3641 for the appropriate fax number. Go to www.nyc.gov/health/diseasereporting for more information.

Patient Information Patient Last Name First Name Middle Name DATE OF REPORT

Patient AKA: Last Name AKA: First Name AKA: Middle Name ______/______/______

Age Date of Birth Country of Birth Social Security Number DATE OF DIAGNOSIS ______/______/______If patient is a child, Guardian Last Name Guardian First Name Guardian Middle Name ______/______/______

Medical Record Number Medicaid Number DATE OF ILLNESS ONSET

Patient Home Address City State Zip Code ______/______/______

Country Borough: M Manhattan M Bronx M Brooklyn M Queens M Staten Island M Unknown M Not NYC

Email Address Mobile Phone Home Phone M Homeless

Sex M Male M Transgender MTF Race M Black M American Indian/Alaska Native M Asian Ethnicity M Hispanic

M Unknown M Female M Transgender FTM M Unknown M White M Native Hawaiian/Pacific Islander M Other: ______M Unknown M Non-Hispanic Is patient alive? M Yes M No M Unknown Is patient pregnant? M Yes M No M Unknown Is case suspected to be due to healthcare associated transmission?

If no, date of death: ______/______/______If yes, due date: ______/______/______M Yes M No M Unknown Was patient admitted to hospital? M Yes M No M Unknown Is patient a newborn infant? M Yes M No M Unknown

Admission date: ______/______/______If yes, name of hospital where infant was born

Discharge date: ______/______/______Name of facility where infant’s mother obtained prenatal care Foreign travel

Countries Date returned to U.S. ______/______/______Other Information Name of Person Reporting Disease Email address Phone r

te Name of Facility of Person Reporting Disease National Provider Identifier (NPI) Code Permanent Facility Identifier (PFI) Code r

Repo Facility Street Address City State Zip Code

Name of Hospital/Healthcare Facility Providing Care for Patient Facility National Provider Identifier (NPI) Code Permanent Facility Identifier (PFI) Code ility c Facility Street Address City State Zip Code Fa

Name of Testing Laboratory Phone CLIA Number ab L Laboratory Street Address City State Zip Code

Name of Provider Caring for Patient National Provider Identifier (NPI) Code Fax r e

d Email address Phone Mobile ovi

Pr Provider Street Address City State Zip Code

Form PD-16 (Rev. 3/2017) -1- Patient Last Name First Name Medical Record Number

Diseases and conditions in green and marked with * are immediately notifable; those marked with † are immediately notifiable if case meets the risk group criteria at the bottom of the page. Report by calling 866-692-3641. For all other diseases and conditions, report using Reporting Central online via NYCMED at www.nyc.gov/health/nycmed, mail this form to the NYC Department of Health and Mental Hygiene, 42-09 28th Street, CN-22, Long Island City, NY 11101, or call 866-692-3641 for the appropriate fax number. Go to www.nyc.gov/health/diseasereporting for more information.

M Amebiasis† M influenzae (invasive disease)† Influenza M Ricin poisoning* M M (Human granulocytic anaplasmosis) Test type: M Suspected novel viral strain with pandemic V Culture V Antigen M Rocky Mountain spotted Animal bite – see Environmental Conditions potential (e.g., avian H5N1 or H7N9)* PCR section on page 3. See rabies if potential for V V Gram stain M Death in a child aged 18 or younger M Rubella (German measles)* V Other ______exposure. Lead poisoning – see Poisonings section on page 3 M Rubella syndrome, congenital † M * Specimen Source: M Legionellosis† M V V CSF V Unknown Serogroup: ______M arboviral , acute* Specify positive test: If due to typhi or paratyphi, ______V Other ______Specify which virus: V Culture V Urine antigen select Typhoid or . If Chikungunya, Dengue, West Nile, Yellow Fever or Specify Serotype: Zika report as such. V DFA V Serology M Severe or novel coronavirus (e.g., SARS or V Type B V Not typeable Attach copies of diagnostic laboratory results if V NAAT or PCR MERS-CoV)* V Not tested V Unknown available. M (Hansen’s disease) M Shiga-toxin producing (STEC) V Other ______M M † † M botulism* M Hantavirus disease* M † M V Foodborne V Infant V Wound M Hemolytic uremic syndrome M M Smallpox (variola)* M * migrans present? M Staphylococcal enterotoxin B poisoning* M † FOR All Hepatitis Reports V Yes V No V Unknown M Staphylococcus aureus, vancomycin intermediate (VISA) and resistant (VRSA)* Carbon Monoxide poisoning* – see Poisonings Jaundice V Yes V No V Unknown M Lymphocytic choriomeningitis virus section on page 3 – see STD section Source: ______ALT (SGPT) value:______V Unknown MIC (µg/ml): – see STD section on page 4 on page 4 ______Lab reference range:______V Unknown † † M Chikungunya M Malaria M (Group A and B) invasive Select at least one of the following: Specify Source: V Blood V CSF V Unknown – see STD section on page 4 M Hepatitis A† V Other, Specify:______Total Ab to Hepatitis A is NOT reportable. V falciparum V vivax V malariae M * IgM anti-HAV: V Pos V Neg V Unknown V ovale V undetermined , including congenital – see STD section Creutzfeldt-Jakob disease – see Transmissable on page 4 M Hepatitis B† Complete Foreign Travel section on page 1. spongiform encephalopathy M Tetanus Report at least one positive hepatitis B test result. M Measles (rubeola)* M Cryptosporidiosis† Total Ab to Hepatitis B is not reportable. M M * M Cyclosporiasis† IgM anti-HBc: V Pos V Neg V Unknown M Trachoma M Meningitis, bacterial M Dengue HBsAg: V Pos V Neg V Unknown M Transmissible spongiform encephalopathy Specify identified ______Attach copies of dengue diagnostic laboratory HBeAg: V Pos V Neg V Unknown (Creutzfeldt-Jakob disease and variants) results if available. M , invasive (including Testing done: ______HBV Nucleic Acid: V Pos V Neg V Unknown (e.g. 14-3-3 on CSF, brain biopsy, autopsy, EEG/MRI) M Diphtheria* meningitis) * If IgM is positive, describe symptoms and risk in Test type/Specimen source: M Trichinosis Drownings – see Environmental Conditions comments box on last page. section on page 3 V Blood culture V CSF culture Tuberculosis – see Tuberculosis section on page 3 Hepatitis  B in pregnancy V Antigen test from CSF V Gram stain M (Human monocytic ehrlichiosis) Report cases in Reporting Central or fax IMM-5 form M * If human granulocytic anaplasmosis report as to 347-396-2558. For more information, call V PCR V Other ______M † anaplasmosis. 347-396-2403. M Monkeypox* M Vaccinia disease (adverse events associated M encephalitis M Hepatitis C† M Mumps† with smallpox vaccination)* If Jul.1–Oct. 31 consider and test for West Nile virus. Check all that apply: M Paratyphoid fever† M Vibrio species, non-cholera If due to another reportable disease (e.g. Lyme, West V EIA pos Nile, arbovirus), report under the other disease. M Pertussis ()† Specify species:______V HCV Nucleic Acid (e.g.PCR) pos M Escherichia coli O157:H7 infection† M Pesticide poisoning - see Poisonings section on M Viral hemorrhagic fever* Is this an acute infection? page 3 M West Nile fever and viral neuroinvasive disease Falls from windows – see Environmental V Yes (e.g., meningitis and encephalitis) Conditions section on page 3 M * V No Attach copies of diagnostic laboratory results Poisoning – see Poisonings section on page 3 if available. M Food poisoning in a group of 2 or more V Unknown individuals* M Poliomyelitis* M Yellow fever* Herpes, neonatal – see STD section on page 4 M Giardiasis† M Psittacosis Attach copies of diagnostic laboratory results if available. M * Hiv/aiDS M * M , non-plague† – see STD section on page 4 Report using the New York State Provider Report M Rabies and exposure to rabies* – see animal Form (PRF). Call 518-474-4284 for forms or M Zika bites in Environmental Conditions section on page 3 – see STD section on page 4 212-442-3388 for more information. *Report suspected and confirmed cases immediately to 1-866-692-3641 †If case meets any of the risk group criteria below, report immediately to 1-866-692-3641 Risk Groups for Disease Exposure/Transmission Complete this section for diseases marked with † and if case meets any criteria, report it immediately to 1-866-692-3641. Patient works in: M Childcare M Health care facility M Long-term care facility/Nursing home M Clinical/Research laboratory M Unknown M Food service M Correctional facility M Position with routine animal contact M Other

Patient attends/resides in: M Assisted living facility M School M Dormitory M Long-term care facility/nursing home M Unknown M Correctional facility M Shelter M Day care/group baby-sit M Other congregate living facility (specify: ______)

-2- Patient Last Name First Name Medical Record Number

Environmental Conditions M animal bites M Drownings M exposure to rabies* Respiratory impairment from submersion/immersion Including a bite or other exposure to any animal confirmed to have rabies, or from any rabies vector species (raccoon, bat, skunk, fox or coyote), in liquid. or any mammal exhibiting signs suggestive of rabies. Drowning Location: ______Outcome: j Death j Morbidity j No Morbidity Animal Species: Date of Bite: ______/______/______Area of body bitten: Breed: Color(s): Activity at time of bite: ______j Owned j Stray j Unknown Place of occurrence:______M Window Falls Owner’s Name: Treatment given: ______Falls from windows of buildings with 3 or more dwellings, by children aged 16 years and younger, report by calling Address: Rabies prophylaxis j Yes j No 646-632-6204 or on Child Window Fall Notification Report City, State, Zip: HRIG j Yes j No paper form. Phone: Rabies j Yes j No Poisonings ROUTE of Exposure CHEMICAL QUANTITY REASON AND SETTING Intentional: SYMPTOM ASSESSMENT (Check all that apply) j Milliliter (mL) ______Unintentional: j Suspected suicide j Ingestion M Lead j None j Seizure j General j Misuse j Ocular For persons aged 16 and older indicate: j Mouthful ______j Electrolyte abnormalities j Environmental j Abuse j Nausea/vomiting/diarrhea Employer______j Sip ______j Dermal j Indoor j Outdoor j Unknown j Lethargic/stupor/coma j Cough/shortness of Employer phone j Tablespoon ______j Inhalation ______j Misuse j Agitated breath Other: M Carbon Monoxide* j Tab/pill/cap ______j Bite/sting j Aural j Contamination/ j Hypertensive j Occular irritation Source: j Furnace/Boiler j Generator j Taste/lick/drop ______j Food poisoning j Bite tampering j Hypotensive j Skin irritation j j Occupational j Vehicle j Other ______Teaspoon ______j Malicious j Tachycardia j Unknown j Sting j j Dietary M arsenic M Cadmium Unknown j Withdrawal j Brachycardia j Other j IV j Consumer product Mercury pesticide M M DATE AND TIME OF EXPOSURE j Pesticide Adverse reaction: ______j M other______/______/______Medication j Drug (accidental ingestion) ______: ______j Food PROVIDER TREATMENT j Unknown j Other j AM j PM j No therapy required j Irrigated eye SPECIMEN SOURCE Laboratory Accession Number j Unknown j Oral fluids j Oxygen j Capillary j Venous j Urine ______j Emesis j Naxolone j Other ______Results (units) ______VITAL SIGNS Resp: ______Pupils: j Lavage j 50% Dextrose/Thiamine Date Collected Body Weight ______Purpose of test: j Activated charcoal j Alkalinize urine j Pounds j Kilograms Temp: ______j F j C j Dilated ______/______/______j Initial j Repeat j Cathartic j N-acetylcysteine (Mucromyst) Date Analyzed j Follow-up Pulse: ______j Constricted j Chelation BP: ______/ ______j Other ______/______/______j Insect sting mgmt.

Tuberculosis Patient status at time of reporting: AFB Smear: CT Scan j / MRI j ___ /___/___ Test for TB Infection: j < 5 years old with LTBI j Positive Body Site: j History of positive test result j TB suspect or case Smear Grade: j suspicious j Chest j Neck Year (yyyy): ______j 1+ rare j 2+ few j Abdomen j Pelvis j 3+ moderate j 4+ numerous j Head j Spine Date of most recent test: ____ /____ /______Indicate all sites of disease for TB suspect or case: j Negative j Pending j j Other: ______Unknown Type of Test: j Pulmonary j Not Done j Unknown j j Lymphatic Nucleic Acid Amplification (NAA): j Normal Tuberculin Skin Test (TST/PPD) j ® Bone/Joint Test type: j Abnormal j Quantiferon TB-Gold in tube (QFT-GIT) j Soft tissue/Muscles j Positive j Negative j j T-Spot.TB Consistent with TB j Peritoneal j Pending j Not Done j Other: ______j Evidence of Cavity j Meningeal j Unknown j Genitourinary Mutation analysis test type: ______j Evidence of Miliary TB Result: Gastrointestinal Mutation detected? j Not consistent with TB j Positive j Negative j Unknown j Other: ______j Yes j No j Unknown j Indeterminate j Borderline If yes, list the genes with mutations:______Collection date: j Unknown Induration ______mm ___ /____/____ M. tb Complex Culture: Positive j Negative Treatment: On Anti-TB Medications j Yes j No j Unknown Laboratory Results: Pending j Contaminated Specimen Number: ______Please complete for each medication: Dose (mg) Frequency/day Start Date Not Done j Unknown j Unknown Medication Dose (mg) Frequency/day Start Date Pathology consistent with TB: Isoniazid (INH) Yes j No j Not Done j Unknown / / Specimen Source: Date: ______/______/______Rifampin (RIF) / / j Sputum Pathology Specimen Number: Pyrazinamide (PZA) j Tracheal aspirate / / Pathology specimen source ______j Bronchial fluid/Broncho-alveolar lavage Ethambutol (EMB) / / Pathology Findings: j Lymph node Other 1 / / j Lung tissue Other 2 / / j Pleural fluid Chest X-Ray: ______/______/______j Pleura j Normal Other 3 / / j Blood j Abnormal

j Urine j Consistent with TB Airborne Isolation: j Yes j No j Unknown j ______j Evidence of Cavity Other: ______If yes, date initiated: _____ /_____ /_____ Date discontinued: _____ /_____ /_____ j Evidence of Miliary TB j Not consistent with TB Describe other medical problems or other pertinent information in the comments box on the last page.

† * Report suspected and confirmed cases immediately to 1-866-692-3641 If case meets any of the risk group criteria on page 2, report immediately to 1-866-692-3641. -3- Patient Last Name First Name Medical Record Number

Sexually Transmitted Diseases For All STD Reports As of the date of this report, Were any of this patient’s sex partners notified Did you provide treatment for any of this Is the patient on pre-exposure prophylaxis Please indicate gender of sexual partners of possible exposure to an STD? patient’s partners? (Check all that apply) (PrEP) to prevent HIV infection? in the past year: (Check all that apply) (Check all that apply) j Yes, I saw the sex partner(s) in my office j Yes, started PrEP at time of current STD j Yes, our office notified the partner(s) j Yes, I gave extra medication for ___(#) partner(s) diagnosis j Males j Yes, the patient was asked to notify partner(s) j Yes, I wrote a prescription for ___(#) partner(s) j Yes, already on PrEP at time of current STD j Females j Transgender Male to Female j j Yes, some other way (specify):______diagnosis No j Transgender Female to Male j No j No j Unknown j Unknown j Unknown j Unknown

Syphilis Test Types: (Check all that apply) M Chancroid M Granuloma inguinale M lymphogranuloma venereum Specify type of specimen: Specify type of specimen: Clinical Presentation (Check all that apply) 1. Serologic tests for syphilis j j j Endocervical j Penile j Vaginal j Endocervical j Proctitis j Penile Vaginal A. Non-treponemal Test j Anorectal j Oropharyngeal j Anorectal j Oropharyngeal j Buboe j kin lesion j RPR Reactive j Non-reactive j Other: j Other j Other:

Specimen collection date: ____ /____ /_____ Specimen collection date: _____ /____ /_____ Specimen collection date: ____ /____ /_____ Titer

Treatment: Treatment: _ Treatment: j VDRL j Reactive j Non-reactive

Treatment date: ____/____ /____ j Unknown Treatment date: ____ /____ /____ j Unknown Treatment date: ____ /____ /____ j Unknown Titer

Chlamydia (CT) Herpes, neonatal Syphilis** M M M Specimen collection date: ____ /____ /_____ Specify type of specimen:  virus infection in infants aged 60 Stage: days and younger. j Endocervical j Urethral j Anorectal j Congenital B. Treponemal Test j j Oropharyngeal j Urine Clinical diagnosis j Primary, present (Check all that apply) j Penile j Vaginal j Endocervical j TP-PA/MHA-TP j Reactive j Non-reactive j Other: j Lab confirmed diagnosis j Anorectal j Oropharyngeal Specify test type: j Culture j PCR j FTA j Reactive j Non-reactive j Other: j Culture j Nucleic acid amplification j Other j Secondary (Check all that apply) j Treponemal IgG j Reactive j Non-reactive j Nucleic acid hybridization Herpes type: j Type 1 j Type 2 j Not typed j EIA j DFA j Alopecia j Condylomata Clinical Syndrome (Check all that apply) Specimen collection date: ____ /____ /_____ j Other: j Mucous patches j j Skin, eye, mucous membrane infection Specimen collection date: ____ /____ /_____ j Early Latent j CNS involvement 2. Cerebrospinal fluid tests Treatment: no symptoms, infection ≤ 1 year duration j Disseminated disease j CSF VDRL j Reactive j Non-reactive Treatment date:___ /____ /___ j Unknown j Late Latent CSF FTA j Reactive j Non-reactive Herpes lesions present? no symptoms, infection of > 1 year duration Result j Yes, anatomic site______j Other Test: M Gonorrhea* (GC) j Tertiary, gumma or cardiovascular j No Specify type of specimen: Neurologic symptoms present? Specimen collection date: ____ /____ /_____ j j j j Unknown Endocervical Urethral Anorectal j Yes j No j Unknown j Oropharyngeal j Urine Specimen collection date:____ /____ / ___ Ocular symptoms present? Elevated CSF protein j Yes j No j Other: Treatment for infant:______j Yes j No j Unknown j Elevated CSF leukocytes j Yes j No Specify test type: Otic symptoms present? Treatment date: ____ /____ /___ j Unknown j Culture j Nucleic acid amplification j Yes j No j Unknown Specimen collection date: ____ /____ /___ j Nucleic acid hybridization Mother’s Name: Treatment – list medication and dosage below: j Other: Mother’s DOB: ____ /____ /_____ 3. Organism visualization

Specimen collection date: ____ /____ /_____ Birth Hospital j Darkfield j Positive j Negative

Treatment 1*: mg/gram Mother’s Labor and Delivery Medical Record No: j Other Test: Result Treatment 2*: mg/gram Treatment date:___ /____ /___ j Unknown Specimen collection date: ____ /____ /_____ Continue to next column Treatment date: ____ /____ /____ j Unknown

* For uncomplicated gonococcal infections of the cervix, urethra, anorectum or , CDC recommends dual therapy (irrespective of concurrent chlamydial infection) using BOTH 250mg IM AND 1g PO. ** Licensed health care providers can access current and historical syphilis test results and treatment information in the New York City Syphilis Registry to inform the diagnosis and management of syphilis in their patients. For more information, see the Syphilis Registry check at: http://www1.nyc.gov/assets/doh/downloads/pdf/std/hcp-syphilis-registry-check.pdf, or call 347-396-7201 Comments:

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