"Zika Virus Report Form" - Connecticut

Zika Virus Report Form is a legal document that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut.

Form Details:

  • Released on September 28, 2016;
  • The latest edition currently provided by the Connecticut State Department of Public Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Public Health.

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Download "Zika Virus Report Form" - Connecticut

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Department of Public Health
Zika Virus Report Form
410 Capitol Avenue, MS#11FDS
P.O. Box 340308
Hartford, CT 06134-0308
(Report by completing and faxing this form to 860-509-7910. For questions, call 860-509-7994.)
Patient’s Telephone
Birth Date
Home
Patient Name (Last)
(First)
(MI)
Parent or Guardian Name
Age
Work
Cell
Address (No. and Street)
(Apt. #)
(City or Town)
(State)
(Zip Code)
(Primary Language Spoken)
 English
 Spanish  Other:
:_____________
specify
Gender  Male  Female  Other
 Unknown
: ________________________
specify
SYMPTOMS
 White
 Black/African American
 Asian
Race
 American Indian/Alaska Native
 Native Hawaiian/Other Pacific Islander
Did patient have symptoms?  Yes
 No
 Unknown
 Other
 Unknown
if yes, check all that apply:
: _____________________________
specify
 Yes
Hispanic/Latino
 Yellow fever
Vaccination History
Primary Symptoms
Symptom onset date: ____________________
 No
 Japanese encephalitis virus
 Yes
 No
 Unknown
 Unknown
Fever
 Yes  No  Unknown # of weeks: _______ Due date: _____________
If yes, temp: ______________
temp date of onset: __________________
Is patient pregnant?
 Yes
 No
 Unknown
Ultrasound findings: __________________
Date: __________________
Rash (maculopapular)
Ultrasound findings: __________________
Date: __________________
 Yes
 No
 Unknown
Arthralgia
 Yes
 No
 Unknown
Conjunctivitis
EPI-link
Guillain–Barré syndrome not known to be associated with another diagnosed etiology?
 Yes
 No
 Unknown
Did patient have recent travel to a Zika virus affected area?
 Yes
 No
 Unknown
If yes, country or countries visited:_________________________________________________
Secondary Symptoms
Date of arrival: ______________________ Date of departure: _________________________
 Yes
 No
 Unknown
Fatigue
 Check if a Sentinel Surveillance System patient (Applies to select clinics ONLY)
 Yes
 No
 Unknown
Chills
 Yes
 No
 Unknown
Headache
Did patient have unprotected sexual contact with a person who traveled to an affected area in the
 Yes
 No
 Unknown
 Yes
 No
 Unk.
Orbital pain
prior 2 weeks?
 Yes
 No
 Unknown
Myalgia
Where did sexual partner travel: _________________________________________
 Yes
 No
 Unknown
Vomiting
 Yes
 No
 Unk. If yes, was test positive?  Y  N
 U
Was sexual partner tested?
 Yes
 No
 Unknown
Diarrhea
 Yes
 No
 Unk.
Did patient receive a blood product within 30 days of symptom onset?
Did patient receive organ transplant within 30 days of symptom onset?  Yes
 No
 Unk.
Reporting healthcare provider name and address:
FOR DPH STAFF USE ONLY
Direct telephone
___________________________
 Yes
 No
Approved for Zika testing:
By: _______
If hospitalized, hospital:
Date Admitted
Date Discharged
(Initials)
Name
Serum
Urine
Specimen Type:
City
Patient ID #
State
Date provider notified: __________________
Name of person completing report:
Address:
Name of person notified: ___________________________By: _______
(Initials)
Phone:
FAX:
Report Date:
(Rev. 09/28/2016).12
Department of Public Health
Zika Virus Report Form
410 Capitol Avenue, MS#11FDS
P.O. Box 340308
Hartford, CT 06134-0308
(Report by completing and faxing this form to 860-509-7910. For questions, call 860-509-7994.)
Patient’s Telephone
Birth Date
Home
Patient Name (Last)
(First)
(MI)
Parent or Guardian Name
Age
Work
Cell
Address (No. and Street)
(Apt. #)
(City or Town)
(State)
(Zip Code)
(Primary Language Spoken)
 English
 Spanish  Other:
:_____________
specify
Gender  Male  Female  Other
 Unknown
: ________________________
specify
SYMPTOMS
 White
 Black/African American
 Asian
Race
 American Indian/Alaska Native
 Native Hawaiian/Other Pacific Islander
Did patient have symptoms?  Yes
 No
 Unknown
 Other
 Unknown
if yes, check all that apply:
: _____________________________
specify
 Yes
Hispanic/Latino
 Yellow fever
Vaccination History
Primary Symptoms
Symptom onset date: ____________________
 No
 Japanese encephalitis virus
 Yes
 No
 Unknown
 Unknown
Fever
 Yes  No  Unknown # of weeks: _______ Due date: _____________
If yes, temp: ______________
temp date of onset: __________________
Is patient pregnant?
 Yes
 No
 Unknown
Ultrasound findings: __________________
Date: __________________
Rash (maculopapular)
Ultrasound findings: __________________
Date: __________________
 Yes
 No
 Unknown
Arthralgia
 Yes
 No
 Unknown
Conjunctivitis
EPI-link
Guillain–Barré syndrome not known to be associated with another diagnosed etiology?
 Yes
 No
 Unknown
Did patient have recent travel to a Zika virus affected area?
 Yes
 No
 Unknown
If yes, country or countries visited:_________________________________________________
Secondary Symptoms
Date of arrival: ______________________ Date of departure: _________________________
 Yes
 No
 Unknown
Fatigue
 Check if a Sentinel Surveillance System patient (Applies to select clinics ONLY)
 Yes
 No
 Unknown
Chills
 Yes
 No
 Unknown
Headache
Did patient have unprotected sexual contact with a person who traveled to an affected area in the
 Yes
 No
 Unknown
 Yes
 No
 Unk.
Orbital pain
prior 2 weeks?
 Yes
 No
 Unknown
Myalgia
Where did sexual partner travel: _________________________________________
 Yes
 No
 Unknown
Vomiting
 Yes
 No
 Unk. If yes, was test positive?  Y  N
 U
Was sexual partner tested?
 Yes
 No
 Unknown
Diarrhea
 Yes
 No
 Unk.
Did patient receive a blood product within 30 days of symptom onset?
Did patient receive organ transplant within 30 days of symptom onset?  Yes
 No
 Unk.
Reporting healthcare provider name and address:
FOR DPH STAFF USE ONLY
Direct telephone
___________________________
 Yes
 No
Approved for Zika testing:
By: _______
If hospitalized, hospital:
Date Admitted
Date Discharged
(Initials)
Name
Serum
Urine
Specimen Type:
City
Patient ID #
State
Date provider notified: __________________
Name of person completing report:
Address:
Name of person notified: ___________________________By: _______
(Initials)
Phone:
FAX:
Report Date:
(Rev. 09/28/2016).12