New Jersey Department of Health

BABESIOSIS Report	Date

CDRSS ID No.

Name (Last)	(First)	(MI)

Sex

Date of Birth (Age)

Street Address

County

City	State	Zip Code

Telephone Number

Race

White	American Indian	Unknown/Other

Black	Asian	Ethnicity

Hispanic	Unknown

Non-Hispanic
Reporting Physician (Name, Address and Telephone No.)

Hospitalized?

Yes

No	Hospital (Name, Address and Telephone No.)

Date of Diagnosis	Onset Date of Illness	Deceased?

Yes

No

Unknown	Case Status

Probable

Confirmed
/	/
/	/
Clinical:
Fever?	Yes No	Highest temp.:	Thrombocytopenia?	Yes No
Chills?	Yes No	Anemia?	Yes No
Headache?	Yes No	Myalgia?	Yes No
Other symptoms:
Risk Factors:
Tick exposure (within last 2 months)?	Yes No Unknown
If yes, when:	Where (county or state if outside of NJ):
History of splenectomy?	Yes No Unknown
If yes, when:
Recent blood transfusion?	Yes No Unknown
If yes, when:	Where:
Was infection transfusion related?	Yes No
Was immunosuppressive condition (e.g., HIV, neoplastic disease or others) present?	Yes No
If yes, specify:
Laboratory Tests (Describe or attach copy of lab reports.):	Date of Specimen Collection
1.	Blood smear positive for Babesia:	Yes No Not Done	/	/
(If Yes, please submit one diagnostic slide to PHEL in Trenton.)
2.	IFA, Total:	Positive Negative Indeterminate
IFA, IgM:	Positive Negative Indeterminate
IFA, IgG:	Positive Negative Indeterminate
3.	Other tests positive for Babesia (e.g., PCR):	Yes No Not Done	/	/
If yes, specify:
Treatment:
Was patient treated with antibiotics for this infection?	Yes No
If yes, specify which drug(s) (Check all that apply):
Clindamycin Quinine Atovaquone Azithromycin Other
Name and Title of Person Submitting Report

Telephone Number

CDS-7

OCT 15

CDS-7, Babesiosis Report

CDS-7, babesiosis report, communicable disease, cds, IZDP, infectious and zoonotic disease program

Elaine White

2012-03-19

ewhite

NJDOH