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This document serves as a notification form to be sent to Community and Public Health regarding a suspected case of pertussis, collecting essential patient information, diagnosis details, immunization
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How to fill out pertussis notification fax form
How to fill out PERTUSSIS NOTIFICATION FAX FORM
01
Obtain the Pertussis Notification Fax Form from your local health department or relevant health authority.
02
Fill in the patient's personal information including name, date of birth, and contact details.
03
Provide a detailed description of the patient’s symptoms and the date of onset.
04
Include relevant medical history and vaccination status.
05
Add emergency contact information.
06
Sign and date the form.
07
Fax the completed form to the appropriate health department or designated authority.
Who needs PERTUSSIS NOTIFICATION FAX FORM?
01
Healthcare providers who diagnose or suspect cases of pertussis in patients.
02
School nurses or administrators managing pertussis cases in educational settings.
03
Public health officials monitoring and controlling pertussis outbreaks.
04
Laboratories reporting confirmed cases of pertussis.
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What is PERTUSSIS NOTIFICATION FAX FORM?
The PERTUSSIS NOTIFICATION FAX FORM is a document used by healthcare providers to report cases of pertussis (whooping cough) to public health authorities.
Who is required to file PERTUSSIS NOTIFICATION FAX FORM?
Healthcare providers, including physicians and clinics, are required to file the PERTUSSIS NOTIFICATION FAX FORM for patients diagnosed with pertussis.
How to fill out PERTUSSIS NOTIFICATION FAX FORM?
To fill out the PERTUSSIS NOTIFICATION FAX FORM, healthcare providers must enter patient details, clinical information about the diagnosis, and any relevant epidemiological data.
What is the purpose of PERTUSSIS NOTIFICATION FAX FORM?
The purpose of the PERTUSSIS NOTIFICATION FAX FORM is to ensure timely reporting of pertussis cases to help monitor outbreaks and implement public health interventions.
What information must be reported on PERTUSSIS NOTIFICATION FAX FORM?
The information that must be reported includes patient demographics, symptoms, onset date, diagnosis confirmation, treatment details, and vaccination history.
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