NOTIFIABLE DISEASE CONDITION REPORT FORM

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					                       NOTIFIABLE DISEASE/
                     CONDITION REPORT FORM
All Georgia physicians, laboratories, and other health care providers are required by law to report patients with conditions of
public health concern listed on the reverse of the enclosed form 3095. Both lab-confirmed and clinical diagnoses are reportable
within the time intervals specified.

Reporting enables appropriate public health follow-up for your patients, helps identify outbreaks, and provides a better
understanding of disease trends in Georgia. For the latest information from the DHR, Division of Public Health, visit their web
site at: www.health.state.ga.us




District Health Office Contact Information

Northwest Health District        Clayton County Board of        North Central Health District        East Health District
Epidemiology Section             Health District                Infectious Disease Unit Supervisor   Epidemiology Unit
1305 Redmond Circle              Administrative Office          811 Hemlock Street                   P.O. Box 15879
Bldg. 614                        1380 Southlake Plaza Dr.       Macon, GA 31201-2198                 Savannah, GA 31416-2579
Rome, GA 30165-1391              Morrow, GA 30260-1756          Phone (478) 751-6214                 Phone (912) 353-3125
Phone (706) 295-6656             Phone (770) 961-1330           FAX (478) 752-1710                   FAX (912) 353-5195
FAX (706) 802-5342               FAX (770) 961-8370
                                                                East Central Health District         Southeast Health District
North Georgia Health District    East Metro Health District     1916 North Leg Rd.                   Office of Infectious Disease
Infectious Disease Department    Epidemiology & Communicable    Augusta, GA 30909-4437               1115 Church Street, Suite A
100 West Walnut Ave., Suite 92   Disease Unit                   Phone (706) 667-4342                 Waycross, GA 31501-3525
Dalton, GA 30720-8417            324 West Pike Street           FAX (706) 667-4728                   Phone (912) 285-6022 (24 hr)
Phone (706) 272-2342             P.O. Box 897                                                        FAX (912) 284-2522
FAX (706) 272-2929               Lawrenceville, GA 30046-0897   West Central Health District
                                 Phone (770) 339-4260           Epidemiology Unit                    Coastal Health District
North Health District            After hours (404) 323-1910     2100 Comer Ave.                      Office of Infectious Diseases
1280 Athens Street               FAX (770) 339-5971             P.O. Box 2299                        777 Gloucester
Gainesville, GA 30507-7000                                      Columbus, GA 31902-2299              Brunswick, GA 31522
Phone (770) 535-5743           DeKalb Health District           Phone (706) 321-6300                 Phone (912) 262-3092
FAX (770) 535-5958             Office of Infectious Diseases    FAX (706) 321-6155                   FAX (912) 261-1964
                               445 Winn Way
Cobb and Douglas Public Health P.O. Box 987                     South Health District                Northeast Health District
Center for Health Assessment   Decatur, GA 30031-1701           Epidemiology                         Epidemiology Section
1650 County Services Pkwy., SW Phone (404) 508-7851             312 North Patterson Street           220 Research Drive
Marietta, GA 30008-4010        FAX (404) 508-7813               P.O. Box 5147                        Athens, GA 30605-2738
Phone (770) 514-2432                                            Valdosta, GA 31603-5147              Phone (706) 583-2868
FAX (770) 514-2313             LaGrange Health District         Phone (229) 333-5290                 FAX (706) 369-5640
                               122 Gordon Commercial Dr.        FAX (229) 259-5003
Fulton Health District         Suite A                          Toll Free 866-801-5360
Fulton County Department of    LaGrange, GA 30240-5740                                                State Contact Information
Health and Wellness            Phone (706) 845-4035             Southwest Health District            Notifiable Diseases
Office of Epidemiology         FAX (706) 845-4038               1306 S. Slappey Blvd., Suite L       Epidemiology Section
99 Jessie Jr. Dr., SE                                           Albany, GA 31701                     Division of Public Health
Atlanta, GA 30303-3045         South Central Health District    Phone (229) 430-7870                 2 Peachtree Street, N.W.
Phone (404) 730-1391           2121-B Bellevue Road             FAX (229) 430-2920                   14th Floor
FAX (404) 730-1397             Dublin, GA 31021-2998                                                 Atlanta, GA 30303-3142
                               Phone (478) 275-6545                                                  Phone (404) 657-2588
                               FAX (478) 275-6575                                                    FAX (404) 657-2608

 Legal Authority: O.C.G.A. §§ 31-12-2, 31-22-7;DHR Rules and Regulations, Notification of Disease, Chapter 290-5-3
                  and Chapter 290-9-8.
Form 3095 (8-04)
                                    GEORGIA NOTIFIABLE DISEASE/CONDITION REPORT FORM
                                             REPORT CASES BY MAIL, FAX OR PHONE TO DISTRICT HEALTH OFFICE
                                                        OR TO SENDSS (http://sendss.state.ga.us)
 Disease/Condition                                                                               Medical Record Number

                                    PATIENT DEMOGRAPHICS                                                             Date of Birth                   Age           Age Type
                                                                                                                     _______/______/_______
Patient’s Name                                                                                                                                                           Yrs
                                                                                                                     Ethnicity               Sex                         Mos
                                                                                                                         Hispanic                   Male                 Weeks
Last Name                                                   First Name                          MI                       Non-Hispanic               Female               Days
                                                                                                                         Unknown                    Unknown              Unk
Patient’s Address
                                                                                                                     Race
                                                                                                                         Asian                             Native Hawaiian or
Street
                                                                                                                         Black/African-American            Pacific Islander
                                                                                                                         Native American or                Other
City                                 State                  Zip+4                               County                   Alaska Native                     Unknown
                                                                                                                         Multiracial                       White
(         )                                        (        )                                          (       )
(         )                                        (        )                                          (       )




                                 L
 Patient’s Home Phone                               Patient’s Work Phone                               Patient’s Other Phone

                                                                         CLINICAL INFORMATION




                               IA
              Illness Onset Date                                                   Y | N | UNK                     Y | N | UNK              Died?        N     Y     UNK
                                                                Hospitalized                         Outpatient                             Date of Death:
          _______/______/_______                                Emergency Rm                                                                _______/______/_________




                              T
If hospitalized, complete:                             Hospital Name                                                             Admit Date                  Discharge Date




      Specimen
    Collection Date


                            EN Test Name
                            (ex. Culture, IFA,
                                                      Specimen Type
                                                                    LABORATORY INFORMATION *Report Hepatitis information in Viral Hepatitis box below

                                                  (ex. Stool, Blood, CSF)
                                                                               Result
                                                                            (ex. +/-, titer,
                                                                                                  Species / Serotype                               Lab Name




                          ID
                               IGM, EIA)                                    Presumptive)




ADDITIONAL INFORMATION
       Pregnant




                        NF
       Nursing Home or other
          Chronic Care Facility
                                                 Yes | No | UNK


                                                                                           Hepatitis A
                                                                                                           *VIRAL HEPATITIS
                                                                                                            Test Results
                                                                                                              Total anti-HAV
                                                                                                              IgM anti-HAV
                                                                                                                                     Date of test(s) _________
                                                                                                                                               Pos | Neg | UNK




                       O
       Child In Daycare                                                                                       HBsAg
       Daycare Worker                                                                      Hepatitis B        Total anti-HBc
       Prisoner/Detainee                                                                                      IgM anti-HBc




                      C
       Food Handler                                                                                           anti-HCV (EIA)
       Health Care Worker
       Outbreak Related                                                                    Hepatitis C        anti-HCV signal to cut-off ratio
       Travel in Last 4 Weeks                                                                                 RIBA
                                                                                                              HCV RNA (PCR, bDNA)
                                                                                                 All          ALT(SGPT)                     AST (SGOT)
                                                                                               Comments/Symptoms/Treatment:
 REPORTER INFORMATION
 Report Date _______/______/_______
 Reporter Name

 Reporter Phone         (        ) _____ - _________
                                                                                           Local Use Only                               State Use Only
 Reporter Institution

 Physician Name

 Physician Phone        (        ) _____ - _________
                                                                                                 Additional form completed

       Need More 3095 Forms                                                                      Name:
       Entered into SENDSS                                                                                                                                           Form 3095 (5-04)
                                                            NOTIFIABLE DISEASE/
                                                           CONDITION REPORTING
                                                  All Georgia physicians, laboratories, and other health care providers are required by law to report
                                            patients with the following conditions. Both lab-confirmed and clinical diagnoses are reportable within the
                                            time interval specified below.
                                                  Reporting enables appropriate public health follow-up for your patients, helps identify outbreaks, and
                                            provides a better understanding of disease trends in Georgia. For the latest information from the DHR,
                                            Division of Public Health, visit their web site at:www.health.state.ga.us

         REPORT IMMEDIATELY                                                     REPORT WITHIN 7 DAYS
                                                                      AIDS (see below, to report)                        legionellosis
   any cluster of illnesses                                           aseptic meningitis                                 leptospirosis
                                                                      campylobacteriosis                                 listeriosis***
   animal bites
                                                                      chancroid                                          Lyme disease
   anthrax                                                            Chlamydia trachomatis (genital                     lymphogranuloma venereum
   all acute arboviral infections:                                       infection)                                      malaria
                                                                      Creutzfeldt-Jakob Disease                          methicillin-resistant S. aureus
       -Eastern Equine Encephalitis (EEE)
                                                                         (CJD), suspected cases,                            (community-associated)#
       -LaCrosse Encephalitis (LAC)                                      under age 55                                    mumps
       -St. Louis Encephalitis (SLE)                                  cryptosporidiosis                                  psittacosis
                                                                      cyclosporiasis                                     Rocky Mountain spotted fever
       -West Nile Virus (WNV)
                                                                      ehrlichiosis                                       rubella (including congenital)
   botulism                                                           giardiasis                                         salmonellosis
   brucellosis                                                        gonorrhea                                          shigellosis
                                                                      HIV (see below, to report)                         streptococcal disease, Group A
   cholera
                                                                      hearing impairment (perma-                            or B (invasive)*
   diphtheria                                                            nent, under age 5)†                             Streptococcus pneumoniae
   E. coli O157:H7                                                    hepatitis B                                           (invasive)*
                                                                            -acute hepatitis B                                 -report with antibiotic-
   Haemophilus influenzae (invasive)*
                                                                            -newly identified HBsAg+                        resistance information
   hantavirus pulmonary syndrome                                         carriers**                                      tetanus
   hemolytic uremic syndrome (HUS)                                          -HBsAg+ pregnant women                       toxic shock syndrome
                                                                      hepatitis C virus infection (past                  toxoplasmosis
   hepatitis A (acute)
                                                                         or present)                                     typhoid
   measles (rubeola)                                                  influenza associated death                         Vibrio infections
   meningitis (specify agent)                                            (under age 18)                                  yersiniosis
                                                                      lead blood level > 10µg/dL
   meningococcal disease
   pertussis                                                                 REPORT WITHIN 1 MONTH
   plague                                                             birth defects‡
                                                                      maternal death##
   poliomyelitis                                                     (Report electronically or call Maternal & Child Health Epidemiology Section, 404-657-6448)
   Q fever
   rabies (human & animal)
                                                                            REPORT WITHIN 4-6 MONTHS
                                                                      benign brain and central nervous system tumors
   severe acute respiratory syndrome (SARS)                           cancer (Refer to the web site http://health.state.ga.us/programs/gccr/reporting.asp)
   shiga toxin positive tests                                       Poster Key
                                                                            Potential agent of bioterrorism.
   S. aureus with vancomycin MIC > 4µg/ml                             *     Invasive = isolated from blood, bone, CSF, joint, pericardial fluid, peritoneal fluid, or
                                                                            pleural fluid.
   smallpox                                                           †     Hearing impairment is reportable to the Children 1st Program
                                                                            (http://health.state.ga.us/epi/disease/hearing.asp).
   syphilis (congenital & adult)                                      **    HBsAg+ = hepatitis B surface antigen positive.
   tuberculosis                                                       ***
                                                                      #
                                                                            L. monocytogenes isolated from any site. Infant mortality is reportable to Vital Records.
                                                                            Resulting in severe illness or death
   latent TB infection, under age 5                                   ##    Maternal deaths during pregnancy or within one year of birth are reportable to Mater-
                                                                            nal and Child Epidemiology (http://health.state.ga.us/epi/mch/publications.asp).
   tularemia                                                          ‡     Birth defects are reportable to the Georgia Birth Defects Reporting and Information
                                                                            System (http://health.state.ga.us/epi/disease/birthdefects.asp).


To Report Immediately    To Report Within 7 Days                                                To Report HIV & AIDS
Call:                    Report cases electronically through the State Electronic               Complete the CDC form 50.42A (available at
District Health Office   Notifiable Disease Surveillance System at                              http://health.state.ga.us/epi/aidsunit.shtml or by calling
(See cover for contact   http://sendss.state.ga.us                                              1-800-827-9769) and mail in an envelope marked
information)             or                                                                     CONFIDENTIAL to:
or                       Complete reverse of this Notifiable Disease Report Form and            Georgia Division of Public Health, Epidemiology Branch
1-866-PUB-HLTH           mail in an envelope marked CONFIDENTIAL or fax to:                     2 Peachtree St. NW, 14th floor - Office 460
(1-866-782-4584)         District Health Office                                                 Atlanta, GA 30303-3189
                         (See cover for contact information)