LABORATORY REPORTABLEREPORTABLE PATHOGEN PATHOGENS CARD PLEASE ANSWER EVERY QUESTIONIN OKLAHOMA ON THE CARD ORGANISM PATIENT’SThe following NAME organisms are to be reported to the OSDH by any laboratory personnel by telephone, ADDRESS FAX, or PHIDDO immediately upon suspicion, diagnosis, or positive test. Bacillus anthracis Outbreaks of apparent infectious organisms CITY ZIP CO. Brucella spp. Poliovirus ClostridiumPHONE( botulinum ) Rubeloa virus (Measles) Corynebacterium diphtheriae Salmonella typhi Francisella tularensisYEARS Variola WHITE virus (Smallpox) Haemophilus influenzaeMONTHS (sterile site MALEonly) Viral BLACK Hemorrhagic Fever HepatitisAGE A (anti-HAVDAYS IgM+) SEX FEMALE RACE YersiniaAMER. pestis IND. HISPANIC YES Neisseria meningitidis (sterile site only) ASIAN ETHNICITY NO OTHER The following organisms are to be reported to the OSDH within one business day AcidWas Fast patient Bacillus hospitalized? (AFB) positive smear Legionella Did patient pneumophila die due this disease ArboviralYes: Name Infections of hospital Leptospira Survived interrogans Bordetella No pertussis Listeria Died: monocytogenesDate of death (sterile site / only) / Borrelia spp. Mumps virus CampylobacterSpecimen Source: spp. Blood Stool CSF Mycobacterium Urine leprae Other Chlamydia psittaci Mycobacterium tuberculosis ClostridiumTest Type: tetani Plasmodium spp. Hepatitis Panel Results: CryptosporidiumCulture parvum Microscopic Exam Gram Stain Rickettsia rickettsii Check applicable box Cyclospora cayetanensis Rubella virus Dengue Antigen virus Test +Salmonella = Positivespp. - = Negative ND = Not Done Ehrlichia Testspp. Method Shigella spp. Escherichia Immunology coli O157,E. coli 0157: H7 or a shiga-like toxin +Streptococcus - ND, group A (sterile site + - only)ND producingTest Method E. coli (EHEC) Streptococcus pneumoniae (sterile site only) Giardia lamblia TreponemaHAV pallidum HBcAb HantavirusTiter/Result Trichinella spiralis Hepatitis B (HBsAg+, anti-HBc IgM+) Unusual HAVIgmor uncommon pathogens HBcIgM Hepatitis RangeC (confirmed by RIBA or PCR only) Vibrio spp. infections including cholera Hepatitis, acute unspecified Yellow FeverHBsAg HBeAg Human ImmunodeficienIf antibody fractioncy Virus performed: (HIV) infection IgM Titer/Result HBsAb HBeBb TheIgG following Titer/Result organisms / test results are to be reported to the OSDH within one month Total Titer/Result HCV HCV Ribal/PCR CD4 Cell Count <500 Creutzfeldt-Jakob Disease Chlamydia trachomatis ALT Neisseria gonorrheaeAST Total Bili

Isolates Other of the following organisms must be sent to the OSDH Public Health Laboratory: (1) Bacillus anthracis Clinical isolate already sentP.O. to Box the Oklahoma24106 OKC, State OK 73124 (2) Brucella spp. Department of Health Public Health Laboratory (3) Campylobacter spp. (9) N. meningitidis (sterile site isolates only) (4)Reporting E. coli O157, Source O157:H7, Information: (10) Plasmodium spp. or a shiga-like toxin producing E. coli (EHEC) (11) Salmonella spp. (5)Laboratory Francisella reporting tularensis (12) Shigella spp. (6) H. influenzae (sterile site isolates only) (13) Vibrio spp. (7)Address Listeria (sterile site isolates only) (14) Yersinia spp. (8)City Mycobacterium tuberculosis State Zip Phone ( ) Physician Clinical specimens for Botulism testing must be sent to the OSDH Public Health Lab HIV/STDCity Service State CommunicablePhone Disease ( Division) Immunization Division (405) 271-4636 (405) 271-4060 (405) 271-4073 FAX (405) 271-1187 FAX (405) 271-6680 FAX (405) 271-6133 FAX (800) 898-6734

FAX machines are located in locked offices and are monitored to ensure the confidentiality of disease reports. LABORATORY REPORTABLE PATHOGEN CARD PLEASE ANSWER EVERY QUESTION ON THE CARD

ORGANISM DATE OF COLLECTION / / PATIENT’S NAME DATE OF FINAL RESULT ADDRESS / / CITY ZIP CO. DATE OF THIS REPORT / / PHONE( ) DATE OF BIRTH / / YEARS WHITE MONTHS MALE BLACK AGE DAYS SEX FEMALE RACE AMER. IND. HISPANIC YES ASIANETHNICITY NO OTHER

Was patient hospitalized? Did patient die due this disease Yes: Name of hospital Survived No Died: Date of death / /

Specimen Source: Blood Stool CSF Urine Other

Test Type: Hepatitis Panel Results: Culture Microscopic Exam Gram Stain Check applicable box

Antigen Test + = Positive - = Negative ND = Not Done Test Method Immunology +- ND +- ND Test Method HAV HBcAb Titer/Result HAVIgm HBcIgM Range HBsAg HBeAg If antibody fraction performed: IgM Titer/Result HBsAb HBeBb IgG Titer/Result Total Titer/Result HCV HCV Ribal/PCR

ALT AST Total Bili

Other Clinical isolate already sent to the Oklahoma State Department of Health Public Health Laboratory

Reporting Source Information: Need more cards? YES Name and address if different from Laboratory reporting left:

Address City State Zip Phone ( ) Physician City State Phone ( )

ODH FORM 295-A

(REV. 08/06)