Form 3095 (8-09) - Notifiable Disease Condition Reporting Page 3
ADVERTISEMENT
1
2
3
4GEORGIA NOTIFIABLE DISEASE/CONDITION REPORT FORM
REPORT CASES BY MAIL, FAX OR PHONE TO DISTRICT HEALTH OFFICE
OR TO SENDSS ( )
Disease/Condition
Medical Record Number
PATIENT DEMOGRAPHICS
Date of Birth
Age
Age Type
_______/______/_______
Yrs
Patient’s Name
Ethnicity
Mos
Sex
Hispanic
Male
Weeks
Non-Hispanic
Female
Last Name
First Name
MI
Days
Unknown
Unknown
Unk
Patient’s Address
Race
Asian
Native Hawaiian or
Street
Black/African-American Pacific Islander
Native American or
Other
Alaska Native
Unknown
City
State
Zip+4
County
Multiracial
White
(
)
(
)
(
)
(
)
(
)
(
)
Patient’s Home Phone
Patient’s Work Phone
Patient’s Other Phone
CLINICAL INFORMATION
Y | N | UNK
Y | N | UNK
Illness Onset Date
Died?
Y
N
UNK
Hospitalized
Outpatient
Date of Death:
_______/______/_______
Emergency Rm
_______/______/_________
Hospital Name
Admit Date
Discharge Date
If hospitalized, complete:
LABORATORY INFORMATION *
Report Hepatitis information in Viral Hepatitis box below
Specimen
Test Name
Specimen Type
Result
Species / Serotype
Lab Name
Collection Date
(ex. Culture, IFA, IGM,
(ex. Stool, Blood, CSF)
(ex. +/-, titer,
EIA)
Presumptive)
ADDITIONAL INFORMATION
*VIRAL HEPATITIS
Date of test(s) _________
Yes |
No | UNK
Test Results
Pregnant
Pos | Neg | UNK
Nursing Home or other
Total anti-HAV
Hepatitis A
Chronic Care Facility
IgM anti-HAV
Child In Daycare
HBsAg
Daycare Worker
Hepatitis B
Total anti-HBc
Prisoner/Detainee
IgM anti-HBc
Food Handler
anti-HCV (EIA)
Health Care Worker
Outbreak Related
Hepatitis C
anti-HCV signal to cut-off ratio
Travel in Last 4 Weeks
RIBA
HCV RNA (PCR, bDNA)
All
ALT(SGPT)
AST (SGOT)
Comments/Symptoms/Treatment:
REPORTER INFORMATION
_______/______/_______
Report Date
Reporter Name
Reporter Phone
(
)
_____ - _________
Local Use Only
State Use Only
Reporter Institution
Physician Name
Physician Phone
(
)
_____ - _________
Additional form completed
Need More 3095 Forms
Name:
Form 3095 (8-09)
Entered into SENDSS
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical