Form DOH-389 "Confidential Case Report" - New York

What Is Form DOH-389?

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

Form Details:

  • Released on February 1, 2011;
  • The latest edition provided by the New York State 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 DOH-389 by clicking the link below or browse more documents and templates provided by the New York State Department of Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form DOH-389 "Confidential Case Report" - New York

382 times
Rate (4.6 / 5) 19 votes
NEW YORK STATE DEPARTMENT OF HEALTH
Confidential Case Report
Division of Epidemiology
County of Residence
Serial #
Date of Report
/
/
Patient Information
Patient’s Name
Last
First
MI
Maiden
Patient’s Alias
Last
First
MI
Guardian’s Name
Last
First
MI
Patient’s Date of Birth
/
/
Patient’s Age
Patient’s Country of Birth
Patient’s Primary Phone No. (
)
-
Patient’s Secondary Phone No. (
)
-
Patient’s Physical Address
Number & Street
City
Zip Code
Patient’s Mailing Address (if different)
City
Zip Code
Occupation (works at)
Setting (resides/attends)
Sex
Race (Check all that apply)
Ethnicity
Food Service
Day Care Facility
Male
White
Hispanic
Day Care
Health Care Facility
Female
Black
Non-Hispanic
Health Care
School
Unknown
Amer. Indian /Alaskan
Unknown
Student/School
Jail/Prison
Asian
Inmate
Camp
Pregnant
Correction Worker
Homeless
Yes
Native Hawaiian/
Pacific Islander
Unemployed
Other
No
Retired
Unknown
Unknown
Other
Other
If Pregnant Due Date:
Unknown
Unknown
/
/
Is Patient Alive?
Yes
No
Unknown
If No, Date of Death
/
/
Disease
Site of Infection
Date of First Symptom:
/
/
Date of Diagnosis
/
/
Hospitalized?
Yes
No
Unknown
Name of Hospital
Medical Record No.
Admission Date
/
/
Discharge Date
/
/
Reporter Information
Reporting Individual
Telephone (
)
-
Address
Reporting Source
MD
Lab
Hospital ICN
School Nurse
Public Health Nurse
Other Local Health Department
Other State Health Dept
Other
Unknown
Provider Name
Provider Telephone
(
)
-
Testing Laboratory
Laboratory Telephone (
)
-
Comments
Include applicable laboratory data, treatment, recent travel, etc.
For Local Health Department Use
Outbreak Related
Case Status
Local Health Department Signature
Was Patient Notified?
Sporadic
Confirmed
Yes
Cluster
Probable
Date Form Received
/
/
No
Outbreak
Suspect
Investigation Start Date
/
/
Unknown
Unknown
Unknown
DOH-389 (2/11) p1 of 2
NEW YORK STATE DEPARTMENT OF HEALTH
Confidential Case Report
Division of Epidemiology
County of Residence
Serial #
Date of Report
/
/
Patient Information
Patient’s Name
Last
First
MI
Maiden
Patient’s Alias
Last
First
MI
Guardian’s Name
Last
First
MI
Patient’s Date of Birth
/
/
Patient’s Age
Patient’s Country of Birth
Patient’s Primary Phone No. (
)
-
Patient’s Secondary Phone No. (
)
-
Patient’s Physical Address
Number & Street
City
Zip Code
Patient’s Mailing Address (if different)
City
Zip Code
Occupation (works at)
Setting (resides/attends)
Sex
Race (Check all that apply)
Ethnicity
Food Service
Day Care Facility
Male
White
Hispanic
Day Care
Health Care Facility
Female
Black
Non-Hispanic
Health Care
School
Unknown
Amer. Indian /Alaskan
Unknown
Student/School
Jail/Prison
Asian
Inmate
Camp
Pregnant
Correction Worker
Homeless
Yes
Native Hawaiian/
Pacific Islander
Unemployed
Other
No
Retired
Unknown
Unknown
Other
Other
If Pregnant Due Date:
Unknown
Unknown
/
/
Is Patient Alive?
Yes
No
Unknown
If No, Date of Death
/
/
Disease
Site of Infection
Date of First Symptom:
/
/
Date of Diagnosis
/
/
Hospitalized?
Yes
No
Unknown
Name of Hospital
Medical Record No.
Admission Date
/
/
Discharge Date
/
/
Reporter Information
Reporting Individual
Telephone (
)
-
Address
Reporting Source
MD
Lab
Hospital ICN
School Nurse
Public Health Nurse
Other Local Health Department
Other State Health Dept
Other
Unknown
Provider Name
Provider Telephone
(
)
-
Testing Laboratory
Laboratory Telephone (
)
-
Comments
Include applicable laboratory data, treatment, recent travel, etc.
For Local Health Department Use
Outbreak Related
Case Status
Local Health Department Signature
Was Patient Notified?
Sporadic
Confirmed
Yes
Cluster
Probable
Date Form Received
/
/
No
Outbreak
Suspect
Investigation Start Date
/
/
Unknown
Unknown
Unknown
DOH-389 (2/11) p1 of 2