OSDH Form 228 "Confidential Morbidity Report of Sexually Transmitted Diseases" - Oklahoma

What Is OSDH Form 228?

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

Form Details:

  • Released on January 1, 2016;
  • The latest edition provided by the Oklahoma 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 fillable version of OSDH Form 228 by clicking the link below or browse more documents and templates provided by the Oklahoma State Department of Health.

ADVERTISEMENT
ADVERTISEMENT

Download OSDH Form 228 "Confidential Morbidity Report of Sexually Transmitted Diseases" - Oklahoma

Download PDF

Fill PDF online

Rate (4.8 / 5) 5 votes
Page background image
Oklahoma State Department of Health
Confidential Morbidity Report of Sexually Transmitted Diseases
Find this and other reporting forms at hivstd.health.ok.gov
A. Patient Information
Patient Name
Current Gender
Sex at Birth
Male
Female
Male
Last:
First:
Middle:
Other
Female
(specify):
Gender of Sexual Partners
Other Names Used
Date of Birth:
(i.e. Married or Maiden Name):
Male Female Both Unknown
/
/
Race
(Check all that apply)
Home Address
Homeless
Incarcerated
(House/Apt # and Street):
Asian
White
Black/African American
American Indian/Alaska Native
City:
State:
Zip Code:
Pacific Islander/Native Hawaiian
Unknown
Other
(specify):
Hispanic Ethnicity
County:
Phone:
Home
Cell
Work
Yes
No
Unknown
B. Diagnosis & Treatment Information
Diagnosis
Prior Syphilis History
Specimen Type
Test Type
CHLAMYDIA
GONORRHEA
Cervical
Pharyngeal
CT Culture
Does patient have prior history of syphilis?
Yes
No
Unknown
Rectal
Serum
CT DNA
SYPHILIS:
Primary
Secondary
Urine
Urethral
GC DNA
Test Date:
Early Latent
Latent
GC Culture
Treatment Date:
Vaginal
Other
(
specify):
Unknown Stage
EIA
Facility:
FTA
Expedited Partner Therapy
Complications/Symptoms
Pregnancy
RPR
Yes;
1
2 3
Congenital Infection*
Rash
Is patient currently pregnant?
# issued=
TPPA
No;
Chancre/lesion
No
Yes
Unknown
specify reason= ___________
Other
(specify):
Pelvic Inflammatory Disease (PID)
___________________________
Number of Weeks:
Unknown
Other Syphilis Symptoms
(specify):
Laboratory Name
Specimen Collection Date
Result
Medication
Dosage
Treatment Date
NKA Allergies (please list: ___________________)
 Azithromycin (Zithromax)
 1g
 2g
 2g plus 240mg Gentamicin
 Ceftriaxone (Rocephin) IM
 250mg
mg
 Doxycycline 100mg PO BID
 7 days
 10 days
 14 days
 Benzathine Penicillin G 2.4 mu IM
 1 dose
 3 doses
 Not Treated  Other
(specify):
C. Provider/Facility Information
Form Completed by:
Physician Name:
Clinic Type: Family Planning Women’s Health Family Medicine
Facility Name:
STD Other
(specify):
Address:
Phone:
(
)
City:
State:
Zip:
Date Form Completed:
1000 N.E. 10
Street, Mail Drop 0308, Oklahoma City, OK 73117
th
Need Supply of:
Phone: (405) 271-4636 | Fax: (405) 271-1187
Forms
**See reverse side for instructions on completing this form
Envelopes
and for information on FREE ELECTRONIC REPORTING**
ODH Form 228
Revised 1/2016
Oklahoma State Department of Health
Confidential Morbidity Report of Sexually Transmitted Diseases
Find this and other reporting forms at hivstd.health.ok.gov
A. Patient Information
Patient Name
Current Gender
Sex at Birth
Male
Female
Male
Last:
First:
Middle:
Other
Female
(specify):
Gender of Sexual Partners
Other Names Used
Date of Birth:
(i.e. Married or Maiden Name):
Male Female Both Unknown
/
/
Race
(Check all that apply)
Home Address
Homeless
Incarcerated
(House/Apt # and Street):
Asian
White
Black/African American
American Indian/Alaska Native
City:
State:
Zip Code:
Pacific Islander/Native Hawaiian
Unknown
Other
(specify):
Hispanic Ethnicity
County:
Phone:
Home
Cell
Work
Yes
No
Unknown
B. Diagnosis & Treatment Information
Diagnosis
Prior Syphilis History
Specimen Type
Test Type
CHLAMYDIA
GONORRHEA
Cervical
Pharyngeal
CT Culture
Does patient have prior history of syphilis?
Yes
No
Unknown
Rectal
Serum
CT DNA
SYPHILIS:
Primary
Secondary
Urine
Urethral
GC DNA
Test Date:
Early Latent
Latent
GC Culture
Treatment Date:
Vaginal
Other
(
specify):
Unknown Stage
EIA
Facility:
FTA
Expedited Partner Therapy
Complications/Symptoms
Pregnancy
RPR
Yes;
1
2 3
Congenital Infection*
Rash
Is patient currently pregnant?
# issued=
TPPA
No;
Chancre/lesion
No
Yes
Unknown
specify reason= ___________
Other
(specify):
Pelvic Inflammatory Disease (PID)
___________________________
Number of Weeks:
Unknown
Other Syphilis Symptoms
(specify):
Laboratory Name
Specimen Collection Date
Result
Medication
Dosage
Treatment Date
NKA Allergies (please list: ___________________)
 Azithromycin (Zithromax)
 1g
 2g
 2g plus 240mg Gentamicin
 Ceftriaxone (Rocephin) IM
 250mg
mg
 Doxycycline 100mg PO BID
 7 days
 10 days
 14 days
 Benzathine Penicillin G 2.4 mu IM
 1 dose
 3 doses
 Not Treated  Other
(specify):
C. Provider/Facility Information
Form Completed by:
Physician Name:
Clinic Type: Family Planning Women’s Health Family Medicine
Facility Name:
STD Other
(specify):
Address:
Phone:
(
)
City:
State:
Zip:
Date Form Completed:
1000 N.E. 10
Street, Mail Drop 0308, Oklahoma City, OK 73117
th
Need Supply of:
Phone: (405) 271-4636 | Fax: (405) 271-1187
Forms
**See reverse side for instructions on completing this form
Envelopes
and for information on FREE ELECTRONIC REPORTING**
ODH Form 228
Revised 1/2016
Oklahoma State Department of Health
Confidential Morbidity Report of Sexually Transmitted Diseases
ODH Form 228 GUIDELINES (Revised 1/2016)
This form is intended for use by all health care providers diagnosing and/or treating sexually transmitted diseases in the state
of Oklahoma. Public Health Codes (OAC § 310:515-1-3 and OAC § 310:515-1-4) require reporting of HIV/AIDS and syphilis
within 24 hours, and chlamydia and gonorrhea within 30 days of diagnosis.
All STD diagnoses, laboratory tests, and treatment information for a patient with multiple STD infections may be
reported on a single form. Report only gonorrhea, chlamydia, or syphilis on this form. The following diseases should be
reported to OSDH separately:
Hepatitis B or Hepatitis C: Please report cases of Hepatitis B or C on ODH Form 295
(available at hivstd.health.ok.gov) or report electronically, using PHIDDO.
HIV/AIDS: Please report cases of adult HIV/AIDS on CDC Form 50.42a and pediatric HIV/AIDS on CDC Form
50.042b (available at hivstd.health.ok.gov) or report electronically, using PHIDDO.
The provider (or designee) is responsible for mailing all original forms to the HIV/STD Service of the Oklahoma State
Department of Health in the confidential, pre-addressed, postage-paid, gray envelopes. All sections of this form must be
completed.
Form Sections:
A.
Patient Information
Complete all entries in full. If patient is under 14 years of age, and abuse or assault is suspected, notify the
Department of Human Services (DHS), as required by Oklahoma law (21 OS § 1112, 21 OS § 1113, 21 OS § 1114,
Schedule S-2).
B.
Diagnosis & Treatment Information
1.
Diagnosis
a. Chlamydia: Check the appropriate box if diagnosing the patient with chlamydia and check the
appropriate box(es) or list any complications present. Complete the prior syphilis history section.
b. Gonorrhea: Check the appropriate box if diagnosing the patient with gonorrhea and check the
appropriate box(es) or list any complications present. Complete the prior syphilis history section.
c. Syphilis: Check the appropriate box if diagnosing the patient with syphilis. Check the appropriate box for
the stage of syphilis (primary, secondary, etc.). Complete the prior syphilis history section. If prior history
exists, give the approximate date of prior test and treatment, and the name and location of prior test and
treatment, if available. Check the appropriate box(es) or list any complications present.
2.
Prior Syphilis History: Complete the prior syphilis section for any diagnosis.
3.
Specimen Type: Check the appropriate box(es) for the type of specimen collected.
4.
Test Type: Check the appropriate box(es) for the type of test performed on the specimen.
5.
Expedited Partner Therapy: Providing treatment or Rx for the sex partners to the persons with sexually transmitted
diseases (STD) without an intervening medical evaluation of the partner(s). Check the appropriate box(es).
6.
Complications and Symptoms: Check the appropriate box(es) or list any complications or symptoms present
with any diagnosis.
7.
Pregnancy: Check the appropriate box for the patient’s current pregnancy status. If the patient is currently
pregnant, specify the number of weeks of gestation at the time of specimen collection.
8.
Laboratory Name: Indicate the laboratory name(s) where each specimen was sent for testing.
9.
Specimen Collection Date: Indicate the date the specimen was collected.
10. Result: Indicate positive, reactive, negative, non-reactive, and specify quantity or titer when applicable.
11. Medication: Check the appropriate box(es), or specify the type of medication given to the patient. If the
patient was not treated, check the appropriate box.
12. Dosage: Check the appropriate box, or specify the dosage of medication given to the patient.
13. Treatment Date: Indicate the date(s) the patient was treated. Please contact (405) 271-4636 with any questions
about treatment recommendations.
C.
Provider/Facility Information
Print, type, or stamp all entries. If your facility is a health department, check the appropriate clinic type. If
applicable, indicate department name (emergency room, pediatric clinic, women’s health, etc.). Check the
appropriate box(es) if more forms and/or envelopes are needed.
*Congenital Infections of chlamydia, gonorrhea or syphilis are conditions present at birth due to maternal infections.
Congenital syphilis is a severe, disabling, and often life-threatening syphilis infection seen in infants.
Electronic Reporting: PHIDDO (Public Health Investigation and Disease Detection of Oklahoma)
PHIDDO is a secure, user-friendly, web-based reporting option for any clinical or healthcare professional required to
submit cases of reportable diseases to OSDH. Because PHIDDO eliminates the need for faxing and mailing reports, it
is our preferred method of reporting. PHIDDO is provided at no cost to your facility. To register or get more
information, please contact:
Tony McCord or Anthony Lee at (405) 271-4060.
Page of 2