Form STD-11 "Std Case Report Form" - New Jersey

What Is Form STD-11?

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 December 1, 2018;
  • 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 fillable version of Form STD-11 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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The State of New Jersey Department of Health
Fax Report to the STD
Sexually Transmitted Disease Program
Confidential Fax Line:
STD CASE REPORT FORM
(609) 826-4870
PO Box 363, Trenton NJ 08625-0363 | 609-826-4869
PATIENT INFORMATION
LAST NAME
FIRST NAME
MIDDLE INITIAL
DATE OF BIRTH
ADDRESS
CITY
STATE
ZIP CODE
TELEPHONE (indicate home, work or cell)
SEX AT BIRTH
CURRENT GENDER
IS PATIENT PREGNANT?
ESTIMATED DELIVERY DATE
(If pregnant):
Male
Female
Male
Female
Yes
No
Unknown
ETHNICITY
RACE (Check all that apply)
GENDER OF SEX
REASON FOR EXAM (Check one)
DATE OF LAST HIV TEST:
PARTNER(S)
Hispanic
White
Black
Asian
Symptomatic
_________________________
Male
Pos
Neg
Unk
Non-Hispanic
Routine exam – no symptoms
American Indian/Alaskan Native
RESULT:
Female
Unknown
Exposed to infection
Native Hawaiian/Other Pacific Islander
IS PATIENT ON PrEP?
Both
Other
Unknown
Yes
No
Unknown
Unknown
DIAGNOSIS – Include lab results when sending case report forms
GONORRHEA
DATE TREATED:___________________________(check all that apply)
Sites (check all that apply)
Ceftriaxone 250mg IM
Azithromycin 1g
Cefixime 400 mg PO
Azithromycin 2g
Cervix
Urethra
Urine
Rectum
Doxycycline 100mg BIDx7
Gentamicin 240mg IM
Gemifloxacin 320mg PO
Pharynx
Vagina
Other:_________________
Other:___________________________________
WAS THE PATIENT GIVEN MEDICATION/PRESCRIPTION FOR THEIR PARTNER(S)?
Yes
No
Unk
CHLAMYDIA
DATE TREATED:___________________________(check all that apply)
Sites (check all that apply)
Azithromycin 1g
Azithromycin 2g
Doxycycline 100mg BIDx7
Cervix
Urethra
Urine
Rectum
Other:___________________________________________________________
Pharynx
Vagina
Other:_________________
WAS THE PATIENT GIVEN MEDICATION/PRESCRIPTION FOR THEIR PARTNER(S)?
Yes
No
Unk
SYPHILIS
Primary (chancre)
Secondary (rash, etc.)
DATE TREATED: ___________________________(check all that apply)
Early latent (<1 year duration but no symptoms)
Bicillin 2.4mu IMx1
Bicillin 2.4mu IMx3wks
Other:________________________
Late latent (>1 year duration but no symptoms)
:________________________________________________________
DESCRIBE SYMPTOMS
WAS THE PATIENT TESTED FOR SYPHILIS PRIOR TO CURRENT REPORT?
Unknown duration
Congenital
Yes
No
Unk
Additional diagnoses (check all that apply):
:
IF YES, DATE OF LAST RPR:_________________________
RESULT
Pos
Neg
Unk
Neuro syphilis
Ocular syphilis
Otic syphilis
OTHER*
Chancroid
Lymphogranuloma Venereum
*Call 609-826-4869 to discuss further
REPORTING CLINIC INFORMATION
PERSON COMPLETING FORM
EXAMINING PROVIDER
DATE
(first)
(last)
(first)
(last)
FACILITY NAME
TELEPHONE
(direct line)
ADDRESS
ZIP CODE
(city)
(state)
(street)
Thank you for reporting a STD. All information will be managed with the strictest confidentiality.
PRIVILEGED AND CONFIDENTIAL COMMUNICATION: The information contained in this message is privileged, confidential or otherwise exempt from disclosure and is intended solely for the use of the individual(s) named above. If
you are not the intended recipient, you are hereby advised that any dissemination, distribution or copying of this communication is prohibited. If you have received this facsimile in error, please immediately notify the sender by
telephone and destroy the original facsimile.
STD-11 | DEC 18
The State of New Jersey Department of Health
Fax Report to the STD
Sexually Transmitted Disease Program
Confidential Fax Line:
STD CASE REPORT FORM
(609) 826-4870
PO Box 363, Trenton NJ 08625-0363 | 609-826-4869
PATIENT INFORMATION
LAST NAME
FIRST NAME
MIDDLE INITIAL
DATE OF BIRTH
ADDRESS
CITY
STATE
ZIP CODE
TELEPHONE (indicate home, work or cell)
SEX AT BIRTH
CURRENT GENDER
IS PATIENT PREGNANT?
ESTIMATED DELIVERY DATE
(If pregnant):
Male
Female
Male
Female
Yes
No
Unknown
ETHNICITY
RACE (Check all that apply)
GENDER OF SEX
REASON FOR EXAM (Check one)
DATE OF LAST HIV TEST:
PARTNER(S)
Hispanic
White
Black
Asian
Symptomatic
_________________________
Male
Pos
Neg
Unk
Non-Hispanic
Routine exam – no symptoms
American Indian/Alaskan Native
RESULT:
Female
Unknown
Exposed to infection
Native Hawaiian/Other Pacific Islander
IS PATIENT ON PrEP?
Both
Other
Unknown
Yes
No
Unknown
Unknown
DIAGNOSIS – Include lab results when sending case report forms
GONORRHEA
DATE TREATED:___________________________(check all that apply)
Sites (check all that apply)
Ceftriaxone 250mg IM
Azithromycin 1g
Cefixime 400 mg PO
Azithromycin 2g
Cervix
Urethra
Urine
Rectum
Doxycycline 100mg BIDx7
Gentamicin 240mg IM
Gemifloxacin 320mg PO
Pharynx
Vagina
Other:_________________
Other:___________________________________
WAS THE PATIENT GIVEN MEDICATION/PRESCRIPTION FOR THEIR PARTNER(S)?
Yes
No
Unk
CHLAMYDIA
DATE TREATED:___________________________(check all that apply)
Sites (check all that apply)
Azithromycin 1g
Azithromycin 2g
Doxycycline 100mg BIDx7
Cervix
Urethra
Urine
Rectum
Other:___________________________________________________________
Pharynx
Vagina
Other:_________________
WAS THE PATIENT GIVEN MEDICATION/PRESCRIPTION FOR THEIR PARTNER(S)?
Yes
No
Unk
SYPHILIS
Primary (chancre)
Secondary (rash, etc.)
DATE TREATED: ___________________________(check all that apply)
Early latent (<1 year duration but no symptoms)
Bicillin 2.4mu IMx1
Bicillin 2.4mu IMx3wks
Other:________________________
Late latent (>1 year duration but no symptoms)
:________________________________________________________
DESCRIBE SYMPTOMS
WAS THE PATIENT TESTED FOR SYPHILIS PRIOR TO CURRENT REPORT?
Unknown duration
Congenital
Yes
No
Unk
Additional diagnoses (check all that apply):
:
IF YES, DATE OF LAST RPR:_________________________
RESULT
Pos
Neg
Unk
Neuro syphilis
Ocular syphilis
Otic syphilis
OTHER*
Chancroid
Lymphogranuloma Venereum
*Call 609-826-4869 to discuss further
REPORTING CLINIC INFORMATION
PERSON COMPLETING FORM
EXAMINING PROVIDER
DATE
(first)
(last)
(first)
(last)
FACILITY NAME
TELEPHONE
(direct line)
ADDRESS
ZIP CODE
(city)
(state)
(street)
Thank you for reporting a STD. All information will be managed with the strictest confidentiality.
PRIVILEGED AND CONFIDENTIAL COMMUNICATION: The information contained in this message is privileged, confidential or otherwise exempt from disclosure and is intended solely for the use of the individual(s) named above. If
you are not the intended recipient, you are hereby advised that any dissemination, distribution or copying of this communication is prohibited. If you have received this facsimile in error, please immediately notify the sender by
telephone and destroy the original facsimile.
STD-11 | DEC 18