Get the free Pertussis Reporting Form For Healthcare Providers - jeffersoncountypublichealth

615 Sheridan Street Port Townsend, WA 98368 www.JeffersonCountyPublicHealth.org Pertussis Reporting Form For Healthcare Providers Notifiable Condition: Today's Date: / / Date of Diagnosis: / / Attending

How to fill out pertussis reporting form for

How to Fill Out Pertussis Reporting Form:

1. Begin by clearly identifying the individual who is reporting the pertussis case. Provide your name, contact information, and any relevant credentials.
2. Next, fill in the patient's information accurately. Include their full name, date of birth, gender, and contact details.
3. Provide the date of onset of symptoms. This is crucial for tracking the progression of the illness and identifying potential outbreaks.
4. Specify the healthcare facility or provider who made the diagnosis. Include their name, address, and contact information.
5. Describe the symptoms exhibited by the patient. Include details such as the duration and severity of coughing fits, any additional signs like whooping sound or vomiting, and any associated complications.
6. Indicate the date of diagnosis and the laboratory that conducted the confirming tests. Include any relevant test results and their interpretations.
7. Provide a brief medical history of the patient, including any underlying medical conditions or medications they are taking.
8. Fill in information related to vaccination history, indicating whether the patient has received the pertussis vaccine and if so, the dates and doses.
9. Specify any known contacts of the patient who may have been exposed to pertussis. Include their names, contact details, and the nature of the contact (e.g., household member, healthcare worker, fellow student).
10. Finally, sign and date the form to certify its accuracy and completeness.

Who Needs Pertussis Reporting Form:

1. Healthcare professionals and providers: Doctors, nurses, and other healthcare personnel involved in diagnosing and treating pertussis cases are required to complete the pertussis reporting form. This helps in monitoring the spread of the disease, tracking outbreaks, and implementing appropriate control measures.
2. Laboratories: Medical laboratories that confirm pertussis infections through diagnostic tests also need to report cases to public health authorities using the pertussis reporting form. This aids in surveillance and monitoring the prevalence of the disease.
3. Public health authorities: Local and state health departments rely on the information provided in the pertussis reporting forms to maintain accurate records, investigate outbreaks, and implement interventions to prevent the further spread of the disease.

Note: The specific individuals and organizations responsible for reporting pertussis may vary depending on the country or region. It is essential to follow the guidelines and regulations set forth by the respective public health authorities.

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