State Form 43823 - Confidential Report Of Communicable Diseases
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DISEASE
CONFIDENTIAL REPORT OF COMMUNICABLE DISEASES
State Form 43823 (R4 / 2-16)
THIS FORM CONTAINS CONFIDENTIAL
INFORMATION PER 410 IAC 1-2.5-78
Name (last, first, middle initial)
If child, name of parent (last, first, middle initial )
Address (number and street)
Occupations of Interest
City
ZIP code
(Not Required For STD's)
Check all that apply:
County
Health Care Worker
Food Service
Telephone
School (student/staff)
Day Care (attendee/staff)
MM / DD / YYYY
Date of birth (
)
SEX
RACE
ETHNICITY
Name of workplace or school/day care:
Male
White
Hispanic
Female
Black
Non-Hispanic
Pregnant?
Yes
No
Unknown
Other _______
Unknown
Multi-racial
CLINICAL
MM / DD / YYYY
Date of diagnosis (
)
Symptoms
MM / DD / YYYY
Onset date (
)
Deceased
Yes
No
Hospitalized
Hospital Name
Yes
No
Admission date (
MM / DD / YYYY
)
Discharge date (
MM / DD / YYYY
)
LABORATORY
Test
Result
MM / DD / YYYY
Specimen collection date (
)
Specimen source
TREATMENT
Treatment (name of antibiotic)
Dosage
Treatment date (
MM / DD / YYYY
)
PROVIDER
Physician name
Person reporting (other than physician)
Facility / Hospital Name
Facility telephone number
Person reporting telephone number
MM / DD / YYYY
Date of report (
)
LOCAL HEALTH DEPARTMENT USE ONLY
MM / DD / YYYY
Date of first notification (
)
Follow-up initiated?
Yes
No
Name of investigator
Investigator telephone number
Fax completed form to the Epidemiology Resource Center of the Indiana State Department of Health at 317-234-2812.
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