New Jersey Department of Health

(For Submission to Local Health Department)	COMMUNICABLE DISEASE REPORT

(NOTE: Shaded areas are for Local Health Department Use Only.)
Name of Disease (Specify Organism)

Setting of Infection

Sporadic Case

Household Cluster

Institutional Cluster

Outbreak	State E No.

E-	CDRS ID No.

Name of Patient (Last)	(First)	(MI)

Date of Birth	Telephone Number

( )
/	/
Month	Day	Year
Onset Date of Illness	Age	If <2 Years	Sex

M

F

Unk.	Race

White	Black	Other

Amer. Indian/Alaskan

Asian/Pacific Islander

Unknown	Other

Ethnicity

Hispanic

Non-Hisp.

Unknown	Patient Pregnant?

Yes

No

Unknown
/	/
Yrs.
Mos.
Mailing Address (Include Name of Institution, if Applicable)

(Street)	(City)	(Zip)	(County)	Residence Location, if Different

Municipality Code of Residence

Occupation/School/Day Care

Child Care Worker	Day Care Attendee

Health Care Worker	Student

Food Handler	Other:	Place of Occupation/School/Day Care Site

Hospital Inpatient?

Yes

No

Unknown	Admission date	Hospital

(Name)	(City)	(State)	Deceased?

Yes

No

Unknown
/	/
Month	Day	Year
Treating Physician Name and Address, If Known

Telephone Number, If Known

( )	Case Status

Possible

Probable

Confirmed
Has Patient Had Recent (in past 6 months):

A. Blood Transfusion?	Yes	No	Unknown	B. Renal Dialysis?	Yes	No	Unknown
Was Travel Associated with Illness?

Yes	No	Unknown	Country/State/County Visited

Date (Month/Day/Year) of Travel

From:	To:
For Vaccine-Preventable Disease, Was Patient Vaccinated?

Yes	No	Unknown	If Vaccinated, Vaccine Used

Date of Immunization
/	/
Month	Day	Year
SUPPORTING LABORATORY RESULTS
No Specimens Collected	Results Pending (Specify):	Unknown
CULTURE POSITIVE

Specimen Collection Date:	Organism:	LAB:
Specimen Source:	Blood	CSF	Stool	Other:
ANTIGEN TEST POSITIVE

(e.g. fluorescent antibody)

Specimen Collection Date:	Organism:	LAB:
Specimen Source:	Sputum	CSF	Urine	Other:
Test Done:	LA	FA	DNA	Other:
SEROLOGY / OTHER TESTS (Please specify test done)
Test Done	First Blood	Second Blood
Date	Pos.	Neg.	Titer	Date	Pos.	Neg.	Titer
Lab Performing Serology / Other Tests, if Known:
Supporting Clinical Information

Name of Person Submitting Report (Print)

Title

Telephone

( )
Name of Reporting Health Officer Representative

Name of Health Department

Date Initially Reported
/	/
Month	Day	Year
CDS-1 AUG 12

CDS-1, Communicable Disease Report

CDS-1, communicable disease report, local health department, reportable disease,

ewhite

2012-03-16

NJDOH