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Case Report Smallpox Case Investigation Supplementary Form 1B Patient Information STATE 1. DATE OF FOLLOW-UP Month Day Year 2. NAME OF PERSON FILING THIS CASE Last First Middle Initial 3. PATIENT S NAME Yes 4. ADMITTED TO 2ND HOSPITAL OR ISOLATION SITE No Unknown IF YES DATE OF ADMISSION HOSPITAL NAME 2nd HOSPITAL MEDICAL RECORD City State Clinical Course 5. SMALLPOX TYPES RASH MOST SEVERE STAGE Ordinary Type Confluent Face and other site Semi-confluent Face only Early Discrete lesions Late...

How to fill out smallpox case investigation supplementary

How to fill out Smallpox Case Investigation Supplementary (Form 1B)

1. Begin by obtaining a copy of the Smallpox Case Investigation Supplementary (Form 1B).
2. Fill out the patient's personal information at the top of the form, including name, date of birth, and contact details.
3. Indicate the date of symptoms onset and any relevant clinical information regarding the smallpox case.
4. Complete the vaccination history section, specifying if the patient has been vaccinated for smallpox and the dates of vaccination.
5. Provide details about the patient's exposure history, including any recent travel or contact with known cases.
6. Include demographic information, such as gender and ethnicity, as requested on the form.
7. If applicable, document any treatments administered and their outcomes.
8. Ensure all information is accurate and complete, then sign and date the form.
9. Submit the form to the designated public health authority as per provided guidelines.

Who needs Smallpox Case Investigation Supplementary (Form 1B)?

1. Healthcare professionals who suspect a case of smallpox.
2. Public health officials conducting investigations of smallpox cases.
3. Epidemiologists tracking smallpox exposure and cases.
4. Researchers studying smallpox outbreaks.
5. Any organization involved in infectious disease response efforts related to smallpox.

For pdfFiller’s FAQs

What is Smallpox Case Investigation Supplementary (Form 1B)?

Smallpox Case Investigation Supplementary (Form 1B) is a form used by health authorities to collect detailed information about suspected or confirmed cases of smallpox in order to monitor outbreaks and implement control measures.

Who is required to file Smallpox Case Investigation Supplementary (Form 1B)?

Health professionals, including physicians and epidemiologists, who identify a suspected or confirmed case of smallpox are required to file Smallpox Case Investigation Supplementary (Form 1B).

How to fill out Smallpox Case Investigation Supplementary (Form 1B)?

To fill out Smallpox Case Investigation Supplementary (Form 1B), provide accurate patient information, clinical findings, vaccination history, epidemiological links, and any laboratory results or case definitions that pertain to the smallpox case.

What is the purpose of Smallpox Case Investigation Supplementary (Form 1B)?

The purpose of Smallpox Case Investigation Supplementary (Form 1B) is to gather essential data to aid in the investigation, containment, and response to smallpox outbreaks, ensuring public health safety.

What information must be reported on Smallpox Case Investigation Supplementary (Form 1B)?

Information that must be reported on Smallpox Case Investigation Supplementary (Form 1B) includes patient demographics, clinical symptoms, vaccination status, potential exposures, travel history, and any laboratory confirmation of the smallpox infection.