Healthcare Surveillance Report

HEALTHCARE SURVEILLANCE REPORT

Purpose: This form documents clinical, laboratory, exposure, and public health reporting information for surveillance of communicable disease and other reportable conditions. Information collected will be used for patient care, public health investigation, contact tracing, infection control, and mandatory reporting as required by law. Provide complete and accurate information. Falsification may be subject to penalties under applicable law.

1. Patient Information

Date of birth:    Gender: Male   Female   Other   Prefer not to say

2. Insurance Information

3. Surveillance Event Details

Date of event:    Time of event:

Surveillance type: Active   Passive   Sentinel   Syndromic

4. Clinical Presentation

Symptom onset date:    Presenting severity: Mild   Moderate   Severe   Critical

Fever   Cough   Shortness of breath   Sore throat

Diarrhea   Vomiting   Headache   Rash

Hospitalized: Yes   No   If hospitalized, admission date: Discharge date:

ICU admission: Yes   No   Mechanical ventilation required: Yes

Outcome: Recovered   Ongoing   Deceased   If deceased, date of death:

5. Laboratory and Diagnostic Tests

Specimen collected date:    Specimen type:

6. Exposure and Epidemiologic Information

Recent travel within 21 days prior to illness: Yes   No

Known contact with confirmed case: Yes   No

Associated with known cluster or outbreak: Yes   No

7. Infection Control Measures

Measures implemented: Isolation precautions   PPE used   Contact tracing   Prophylaxis

8. Public Health Reporting and Classification

Reported to public health authority: Yes   No

Case classification (select applicable): Suspect   Probable   Confirmed   Lab-confirmed   Epi-linked

9. Privacy, Authorization and Expiration

Authorization: By signing below I authorize the release of my protected health information, limited to the data elements contained in this report, to the receiving health care facility and public health authorities for surveillance, contact tracing, investigation, and infection control purposes. I understand that reporting of certain conditions is required by law and that such disclosures may be made without my further permission where required.

Expiration of this authorization: (If left blank, authorization valid for the duration necessary for public health response.)

10. Certifications and Warnings

Certification: I certify that, to the best of my knowledge, the information provided on this form is complete and accurate. I understand that information provided will be included in official public health records and may be used to inform public health action. I acknowledge that unauthorized alteration or omission of this form may be subject to penalties as provided by law.

If this form is completed by a legally authorized representative or guardian, indicate relationship below and sign in the patient signature block.

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