Form IMM-23 "Meningococcal Disease Case Report" - New Jersey

What Is Form IMM-23?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2014;
  • The latest edition provided by the New Jersey Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form IMM-23 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form IMM-23 "Meningococcal Disease Case Report" - New Jersey

Download PDF

Fill PDF online

Rate (4.6 / 5) 17 votes
Page background image
New Jersey Department of Health
Report Status
Vaccine Preventable Disease Program
Confirmed
Probable
Not a Case
PO Box 369
CDRSS#
E#
Trenton, NJ 08625-0369
MENINGOCOCCAL DISEASE CASE REPORT
REPORTING INFORMATION
Reported By
Date Reported to LHD/State
Telephone No.
_ _ / _ _ / _ _ _ _
( _ _ _ ) _ _ _ - _ _ _ _
Reporting Site/Clinic
Town/City
County
Type of Reporting Site
College/University
Healthcare Provider
Correctional Facility
School/Day Care
Health Department
Other:
PATIENT INFORMATION
Patient Name (Last, First)
Date of Birth
Age
_ _ / _ _ / _ _ _ _
Address
Telephone Number
Secondary Telephone Number
( _ _ _ ) _ _ _ - _ _ _ _
( _ _ _ ) _ _ _ - _ _ _ _
City
Zip Code
County
Race
Ethnicity
Sex
White
Asian/Pacific Islander
Hispanic
Male
Black
Alaskan/Native American
Non-Hispanic
Female
Unknown
Other:
Unknown
Alternate Address (If applicable, e.g., school, dormitory)
Telephone Number
( _ _ _ ) _ _ _ - _ _ _ _
City
State
Zip Code
County
Emergency Contact (Last, First)
Telephone Number
( _ _ _ ) _ _ _ - _ _ _ _
Relationship
Parent/Guardian
Spouse
Sibling
Other (specify):
CLINICAL INFORMATION
Illness Onset Date
Date of Initial Healthcare Evaluation
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
Medical Facility
Telephone Number
( _ _ _ ) _ _ _ - _ _ _ _
Treating Physician
Telephone Number
( _ _ _ ) _ _ _ - _ _ _ _
Primary Care Physician
Telephone Number
( _ _ _ ) _ _ _ - _ _ _ _
Symptoms
Altered Mental Status
Fever (highest recorded:
)
Nausea
Shock
Chills
Headache
Petechial Rash
Stiff Neck
Coma
Malaise
Photophobia
Vascular Disease
Fatigue
Meningitis
Purpuric Rash
Vomiting
Other:
IMM-23
OCT 14
Page 1 of 3 Pages.
New Jersey Department of Health
Report Status
Vaccine Preventable Disease Program
Confirmed
Probable
Not a Case
PO Box 369
CDRSS#
E#
Trenton, NJ 08625-0369
MENINGOCOCCAL DISEASE CASE REPORT
REPORTING INFORMATION
Reported By
Date Reported to LHD/State
Telephone No.
_ _ / _ _ / _ _ _ _
( _ _ _ ) _ _ _ - _ _ _ _
Reporting Site/Clinic
Town/City
County
Type of Reporting Site
College/University
Healthcare Provider
Correctional Facility
School/Day Care
Health Department
Other:
PATIENT INFORMATION
Patient Name (Last, First)
Date of Birth
Age
_ _ / _ _ / _ _ _ _
Address
Telephone Number
Secondary Telephone Number
( _ _ _ ) _ _ _ - _ _ _ _
( _ _ _ ) _ _ _ - _ _ _ _
City
Zip Code
County
Race
Ethnicity
Sex
White
Asian/Pacific Islander
Hispanic
Male
Black
Alaskan/Native American
Non-Hispanic
Female
Unknown
Other:
Unknown
Alternate Address (If applicable, e.g., school, dormitory)
Telephone Number
( _ _ _ ) _ _ _ - _ _ _ _
City
State
Zip Code
County
Emergency Contact (Last, First)
Telephone Number
( _ _ _ ) _ _ _ - _ _ _ _
Relationship
Parent/Guardian
Spouse
Sibling
Other (specify):
CLINICAL INFORMATION
Illness Onset Date
Date of Initial Healthcare Evaluation
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
Medical Facility
Telephone Number
( _ _ _ ) _ _ _ - _ _ _ _
Treating Physician
Telephone Number
( _ _ _ ) _ _ _ - _ _ _ _
Primary Care Physician
Telephone Number
( _ _ _ ) _ _ _ - _ _ _ _
Symptoms
Altered Mental Status
Fever (highest recorded:
)
Nausea
Shock
Chills
Headache
Petechial Rash
Stiff Neck
Coma
Malaise
Photophobia
Vascular Disease
Fatigue
Meningitis
Purpuric Rash
Vomiting
Other:
IMM-23
OCT 14
Page 1 of 3 Pages.
MENINGOCOCCAL DISEASE CASE REPORT
(Continued)
CLINICAL INFORMATION, CONTINUED
Admission Date:
_ _ / _ _ / _ _ _ _
Medical Record Number:
Discharge Date:
_ _ / _ _ / _ _ _ _
Treatment
Was Patient Admitted through ED?
Yes
No
Medication: __________________________
Dose:
Date(s): _ _ / _ _ / _ _ _ _ - _ _ / _ _ / _ _ _ _
Was Patient Admitted to ICU?
Yes
No
Medication: __________________________
Dose:
Was Patient on a Mechanical Ventilator?
Yes
No
Date(s): _ _ / _ _ / _ _ _ _ - _ _ / _ _ / _ _ _ _
Is Patient Deceased?
Yes
No
Medication: __________________________
Dose:
If Yes, Date of Death:
_ _ / _ _ / _ _ _ _
Date(s): _ _ / _ _ / _ _ _ _ - _ _ / _ _ / _ _ _ _
Is Patient Pregnant?
Yes
No
Unknown
If Yes, Estimated Delivery Date: _ _ / _ _ / _ _ _ _
Risk Factors
Previous History of Vaccination?
Active or Passive Smoking
Yes
No
Unknown
Recent Respiratory Illness
If Yes:
Underlying Condition/Immunosuppressed (specify):
MCV4
MPSV4
Other (specify):
Known Exposure to Other Case
Date of First Dose: _ _ / _ _ / _ _ _ _
Lives in College Dorm/Military Barracks
Brand:
Recent Travel
Date of Second Dose: _ _ / _ _ / _ _ _ _
Other (specify):
Brand:
Is Patient part of a Cluster/Outbreak?
Is Patient a Known MSM?
Yes (Name of Outbreak): ____________________
No
Unknown
Yes
No
Unknown
LABORATORY INFORMATION
Date of Blood Specimen Collection: _ _ / _ _ / _ _ _ _
Date of CSF Specimen Collection: _ _ / _ _ / _ _ _ _
Gram Stain:
Gram-negative Diplococci
No Organism
Gram Stain:
Gram-negative Diplococci
No Organism
Culture Result:
N. meningitidis
No Growth
Culture Result:
N. meningitidis
No Growth
Was Specimen Collected Prior to Treatment?
Was Specimen Collected Prior to Treatment?
Yes
No
Unknown
Yes
No
Unknown
CSF Characteristics
Serum Characteristics
N/A
Color/Clarity:
N/A
Pressure:
N/A
Protein:
Glucose:
RBC Count:
WBC Count:
Predominate Cell Type:
Other Laboratory Test (specify): ____________________
Result: ____________________
Collection Date: _ _ / _ _ / _ _ _ _
Was Specimen Collected Prior to Treatment?
Specimen: ____________________
Yes
No
Unknown
ADDITIONAL COMMENTS
IMM-23
OCT 14
Page 2 of 3 Pages.
MENINGOCOCCAL DISEASE CASE REPORT
CONTACT FOLLOW-UP
Record information of close contacts below. All household members (including roommates), and any person who may have had contact with oral secretions should be included.
Nature of
Previous
Recommended
Taken
Contact*
Date(s) of
Date of
Immunization?
Prophylaxis
Name of Contact
Sex
Phone
Prophylaxis?
Prophylaxis
(List # of all
Exposure
Birth
(Provide dates if
Type(s) and Dates
(Y/N)
(Y/N/Unknown)?
that apply)
known)
*Nature of Contact:
(1) Household (includes roommates in dormitories)
(5) Preschool/Day Care (younger than kindergarten)
(2) Intimate contact (including kissing)
(6) Healthcare/EMS worker exposed to patient’s oral/nasal secretions through
(3) Shared food, drink, cigarettes, lipstick, or any articles put in/on mouth
unprotected mouth-to-mouth resuscitation, intubation, or suctioning
(4) Overnight stay
(7) Other (explain)
IMM-23
OCT 14
Page 3 of 3 Pages.
Page of 3