Confidential Communicable Disease Report Dhhs_2124 2124 Dhhs
User Manual: 2124
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ATTENTION HEALTH CARE PROVIDERS:
Please report relevant clinical findings about this
disease event to the local health department.
North Carolina Department of Health and Human Services
Division of Public Health • Epidemiology Section
Communicable Disease Branch
Birthdate (mm/dd/yyyy)
/ /
SSN
Patient’s Last Name First Middle Suffix Maiden/Other Alias
NC Electronic Disease Surveillance System NC EDSS EVENT ID# ____________________
Instructions for completing the Communicable Disease
Report Form can be found in the NC Public Health
Communicable Disease Manual online at:
www.epi.state.nc.us/epi/gcdc/manual/toc.html.
Questions? Concerns? Contact the NC EDSS Helpdesk:
Phone: ......................................................(919) 715-5548
Toll Free: ...................................................(877) 625-9259
Email: ...................................ncedsshelpdesk@ncmail.net
NC EDSS
LAB RESULTS
Verify if lab results for this event are in NC EDSS. If not present, enter results.
Patient’s Last Name First Middle SuffixMaiden/Other Alias
Birthdate (mm/dd/yyyy)
Age Age Type
Years
Months
Weeks
Days
Race (check all that apply):
White
Black/African American
American Indian/Alaska Native
Asian
Other
Unknown
Ethnic Origin
Hispanic
Non-Hispanic
Sex
M F Trans.
Parent or Guardian (of minors) Medical Record Number
Patient is associated with (check all that apply):
Child Care (child, household contact,
or worker in child care)
School (student or worker)
College/University (student or worker)
Food Service (food worker)
Health Care (health care worker)
Correctional Facility (inmate or worker)
Long Term Care Facility (resident or worker)
Military (active military, dependent,
or recent retiree)
Travel (outside continental United States
in last 30 days)
Is the patient part of an outbreak of this disease? Yes No
Outbreak setting: Household/Community (specify index case):______________________________
Restaurant/Retail
Child Care
Long term care
Healthcare setting
Adult care home
In what geographic location was the patient MOST LIKELY exposed?
In patient’s county of residence
Outside county, but within NC - County: ________________________
Out of state - State/Territory: _________________________________
Out of USA - Country: _______________________________________
Unknown
Did patient die from
this disease?
Yes No
Is the patient
pregnant?
Yes No
Was patient hospitalized for
this disease? (>24 hours)
Yes No
Initial Date of Report to Public Health:____/____/_______
Initial Source of Report to Public Health:
Health Care Provider (specify):
Hospital
Private clinic/practice
Health Department
Correctional facility
Laboratory
Other
Specimen
Date
Specimen # Specimen
Source
Type of Test Test
Result(s)
Description (comments) Result Date Lab Name—City/State
/ / / /
/ / / /
/ / / /
Is/was patient symptomatic for
this disease? .................................. Y N U
If yes, symptom onset date (mm/dd/yyyy): / /
SPECIFY SYMPTOMS:
If a sexually transmitted disease, give specific treatment details
1. Date patient treated:(mm/dd/yyyy) ____________
Medication ______________________________
Dosage _________________________________
Duration ________________________________
DHHS 2124 (Revised January 2016) EPIDEMIOLOGY
Patient’s Street Address City State ZIP County Phone
(_____) _____-_______
Confidential Communicable Disease Report—Part 1
CLINICAL INFORMATION
NAME OF DISEASE / CONDITION
LOCAL HEALTH DEPARTMENT USE ONLY
Health Care Provider for this disease (if not reporting physician):
____________________________________________________________
Contact Person/Title: ___________________________________________
Phone: (______) ______– ________ Fax: (______) ______– __________
Reporting Physician/Practice:
____________________________________________________________
Contact Person/Title: ___________________________________________
Phone: (_____) _____–_________ Fax:(_____) _____– _______________
2. Date patient treated:(mm/dd/yyyy) ____________
Medication ______________________________
Dosage _________________________________
Duration ________________________________
DIAGNOSTIC TESTING
Provide lab information below and fax copy of lab results and other pertinent records to local health department.
Date / /
Assisted living facility
Adult day care
School
Prison
Name of facility___________________________
Address of facility_________________________
________________________________________
Native Hawaiian or Pacific Islander
DISEASE/CONDITION
A-G
ANTHRAX ...............................................................................................
BOTULISM, FOODBORNE ....................................................................
BOTULISM, INTESTINAL (INFANT) ......................................................
BOTULISM, WOUND ..............................................................................
Campylobacter infection ..........................................................................
Chancroid ................................................................................................
Cholera ....................................................................................................
Cryptosporidiosis .....................................................................................
Cyclosporiasis .........................................................................................
Diphtheria ................................................................................................
E. coli infection, shiga toxin-producing .....................................................
Foodborne disease: Clostridium perfringens .............................................
Foodborne: staphylococcal......................................................................
Foodborne disease: other/unknown ........................................................
Foodborne poisoning: ciguatera ..............................................................
Foodborne poisoning: mushroom ............................................................
Foodborne poisoning: scombroid fish......................................................
Gonorrhea ...............................................................................................
Granuloma inguinale ...............................................................................
H-N
Haemophilus influenzae,
invasive disease ....................................................................................
Hemolytic-uremic syndrome (HUS) .........................................................
HEMORRHAGIC FEVER VIRUS
INFECTION .............................................................................................
Hepatitis A................................................................................................
Hepatitis B, acute ....................................................................................
HIV/AIDS
HIV.........................................................................................................
AIDS ......................................................................................................
Influenza virus infection causing death ....................................................
Listeriosis.................................................................................................
Measles (rubeola) ....................................................................................
Meningococcal disease, invasive ............................................................
Monkeypox ..............................................................................................
NOVEL INFLUENZA VIRUS INFECTION ...............................................
O-U
Ophthalmia neonatorum ..........................................................................
Pertussis (Whooping Cough)...................................................................
PLAGUE ..................................................................................................
Poliomyelitis, paralytic .............................................................................
Rabies, human ........................................................................................
Rubella ....................................................................................................
Salmonellosis ..........................................................................................
S. aureus with reduced susceptibility to vancomycin ..............................
SARS coronavirus infection ..................................................................
Shigellosis ...............................................................................................
SMALLPOX .............................................................................................
Syphilis
primary...................................................................................................
secondary ..............................................................................................
early latent .............................................................................................
late latent ...............................................................................................
late with clinical manifestations ..............................................................
congenital ..............................................................................................
Tuberculosis ............................................................................................
TULAREMIA ...........................................................................................
Typhoid Fever, acute ...............................................................................
V-Z
Vaccinia ...................................................................................................
Vibrio infection, other than cholera & vulnificus .......................................
Vibrio vulnificus .......................................................................................
Zika..........................................................................................................
DISEASE/CONDITION
A-G
Brucellosis ................................................................................................
Chlamydial infection— laboratory confirmed ............................................
Creutzfeldt-Jakob Disease .......................................................................
Dengue .....................................................................................................
Ehrlichiosis, HGA (human granulocytic anaplasmosis) ............................
Ehrlichiosis, HME (human monocytic or e. chaffeensis) ..........................
Ehrlichiosis, unspecified ...........................................................................
Encephalitis, arboviral, WNV ....................................................................
Encephalitis, arboviral, LAC .....................................................................
Encephalitis, arboviral, EEE .....................................................................
Encephalitis, arboviral, other ....................................................................
H-N
Hantavirus infection ..................................................................................
Hepatitis B, carriage .................................................................................
Hepatitis B, perinatally acquired ...............................................................
Hepatitis C, acute .....................................................................................
Legionellosis .............................................................................................
Leprosy ....................................................................................................
Leptospirosis ............................................................................................
Lyme disease ...........................................................................................
Lymphogranuloma venereum ...................................................................
Malaria ......................................................................................................
Meningitis, pneumococcal ........................................................................
Mumps ......................................................................................................
Non-gonococcal urethritis .........................................................................
O-Z
Pelvic inflammatory disease......................................................................
Psittacosis ................................................................................................
Q fever ......................................................................................................
Rocky Mountain Spotted Fever ................................................................
Rubella, congenital syndrome ..................................................................
Streptococcal infection, Group A, invasive ...............................................
Tetanus .....................................................................................................
Toxic shock syndrome, non-streptococcal ................................................
Toxic shock syndrome, streptococcal .......................................................
Trichinosis ................................................................................................
Typhoid, carriage (Salmonella typhi) ........................................................
Yellow fever ..............................................................................................
Reportable to Local Health Department Within
7 Days
Reportable to Local Health Department Within
24 Hours
:
DHHS 2124 (Revised January 2016) EPIDEMIOLOGY
Diseases in BOLD ITALICS should be reported immediately to local health department.
Chikungunya ............................................................................................
Middle East respiratory syndrome (MERS) .............................................
North Carolina General Statute:
§130A-135. Physicians to report.
A physician licensed to practice medicine who has reason to suspect that a
person about whom the physician has been consulted professionally has a
communicable disease or communicable condition declared by the
Commission to be reported, shall report information required by the
Commission to the local health director of the county or district in which
the physician is consulted.
North Carolina Administrative Code:
10A NCAC 41A.0101 Reportable Diseases and Conditions
(a) The following named diseases and conditions are declared to be
dangerous to the public health and are hereby made reportable within the
time period specified after the disease or condition is reasonably
suspected to exist:
Physicians must report these diseases and conditions to the county local health department, according to the North Carolina
Administrative Code: 10A NCAC 41A.0101 Reportable Diseases and Conditions (see below). Contact information for local
health departments can be accessed at www.ncalhd.org/directors. If you are unable to contact your local health department,
call the 24/7 pager for N.C. Communicable Disease Branch (919) 733-3419.
For diseases and conditions required to be reported within 24 hours, the initial report shall be made by telephone to the local
health department, and the written disease report be made within 7 days. The reporting rules and disease report forms can be
accessed at: http://epi.publichealth.nc.gov/cd/report.html
You may be contacted by the local health department
for additional information about this case. Medical
record information relevant to the investigation and/or
control of a communicable disease is exempt from the
HIPAA Privacy Rule (see 45 CFR 164.512(a) ) and is
permitted as an exception to confidentiality of records in
NC State Law GS § 130 A-130.
Diseases and Conditions Reportable in North Carolina
