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NEW YORK STATE DEPARTMENT OF HEALTH Blood and Tissue Resources Program Transfusion/Blood Bank related Incident Report Wadsworth Center P.O. Box 509, Empire State Plaza Albany, New York 122010509 Incident
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How to fill out doh 3336 form
Who needs doh 3336?
01
Healthcare providers: The doh 3336 form is primarily needed by healthcare providers such as hospitals, clinics, and medical laboratories. It is a reporting form used to provide information related to communicable diseases.
02
Laboratory facilities: Laboratories performing tests for infectious diseases are required to fill out the doh 3336 form to report positive test results and other relevant details.
03
Public health agencies: Public health agencies at local, state, and federal levels may require healthcare providers and laboratories to submit doh 3336 forms for disease surveillance and monitoring purposes.
How to fill out doh 3336?
01
Personal information: Begin by providing personal information such as your name, contact details, and the name of the healthcare facility or laboratory.
02
Patient information: Fill in the patient's details, including their full name, date of birth, gender, phone number, and address. This information helps in identifying the individual and tracking the disease.
03
Disease information: Specify the disease being reported by providing the name, code, and any other relevant information about the infection or condition.
04
Specimen details: If applicable, indicate the type of specimen collected for testing, such as blood, urine, or throat swab. Include the date of specimen collection and the testing laboratory's name.
05
Test results: Record the results of the laboratory tests conducted, including any quantitative measurements, such as viral loads or antibody titers. Indicate if the test result is positive, negative, or inconclusive.
06
Treatment information: If the patient has received any specific treatment for the reported disease, provide details such as the name of the medication, dosage, frequency, and duration.
07
Reporting details: Include the date the report is being submitted and the name and contact information of the person completing the form for any follow-up correspondence.
08
Signature and certification: Sign and certify the form to confirm the accuracy and completeness of the information provided.
It is essential to ensure accurate and timely submission of the doh 3336 form as it plays a crucial role in disease surveillance, monitoring, and implementation of appropriate public health measures.
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What is doh 3336?
doh 3336 is a form used to report certain information to the Department of Health.
Who is required to file doh 3336?
Healthcare providers and facilities are required to file doh 3336.
How to fill out doh 3336?
doh 3336 can be filled out online through the Department of Health's website or manually on a paper form.
What is the purpose of doh 3336?
The purpose of doh 3336 is to gather data on healthcare services provided and improve public health programs.
What information must be reported on doh 3336?
Information such as patient demographics, services provided, and healthcare provider information must be reported on doh 3336.
When is the deadline to file doh 3336 in 2024?
The deadline to file doh 3336 in 2024 is December 31st.
What is the penalty for the late filing of doh 3336?
The penalty for the late filing of doh 3336 may include fines or other sanctions imposed by the Department of Health.
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