Get the free DSHS Chik-Den-Zika supplemental form rev 09-16.docx - houstontx

Zoonotic Control Branch Chikungunya, Dengue, and Zika Testing Supplemental Information PLEASE PRINT CLEARLY AND COMPLETE ALL SECTIONS. This information is REQUIRED prior to testing. This form should

How to fill out dshs chik-den-zika supplemental form

How to fill out DSHS Chik-den-zika supplemental form:

1. Start by carefully reading the instructions provided on the form. This will help you understand the purpose and requirements of the form.
2. Gather all the necessary information and documentation before starting to fill out the form. This may include personal information, medical history, and any relevant test results or diagnoses.
3. Begin by entering your personal details, such as your name, address, date of birth, and contact information. Ensure that all information is accurately and legibly written.
4. Proceed to the section that asks for your medical history related to Zika virus or Chikungunya virus. Answer all questions honestly and provide any requested information or details about your symptoms, diagnoses, or test results.
5. If you have traveled to any Zika- or Chikungunya-affected areas recently, make sure to provide the dates and locations of your travel. This will help the authorities track any potential outbreaks or transmission of the viruses.
6. Complete any additional sections or questions that are relevant to your situation or may be required by the form. Follow any specific instructions provided.
7. Review the filled-out form carefully to eliminate errors or missing information. Double-check spellings, dates, and any supporting documentation that may need to be attached.
8. Sign and date the form at the designated areas, certifying that all the information provided is true and accurate to the best of your knowledge.
9. Make copies of the completed form for your records before submitting it to the relevant authority or organization.
10. Seek assistance or clarification from the DSHS (Department of State Health Services) or appropriate healthcare professionals if you encounter any difficulties or have questions during the filling-out process.

Who needs DSHS Chik-den-zika supplemental form?

1. Individuals who have been potentially exposed to or diagnosed with Zika virus or Chikungunya virus.
2. People who have recently traveled to areas with ongoing Zika virus or Chikungunya virus transmission.
3. Healthcare providers or authorities responsible for tracking and monitoring Zika virus or Chikungunya virus cases.

Note: The specific eligibility and requirements for filling out the DSHS Chik-den-zika supplemental form may vary. It is important to refer to the official guidelines and instructions provided by the DSHS or relevant health authorities for accurate and up-to-date information.

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What is dshs chik-den-zika supplemental form?

The DSHS Chik-Den-Zika supplemental form is a form used to report cases of chickenpox, dengue, and Zika viruses to the Department of State Health Services.

Who is required to file dshs chik-den-zika supplemental form?

Healthcare providers and laboratories are required to file the DSHS Chik-Den-Zika supplemental form.

How to fill out dshs chik-den-zika supplemental form?

The DSHS Chik-Den-Zika supplemental form can be filled out online through the DSHS website or submitted via mail or fax.

What is the purpose of dshs chik-den-zika supplemental form?

The purpose of the DSHS Chik-Den-Zika supplemental form is to track and monitor incidences of chickenpox, dengue, and Zika viruses in the state of Texas.

What information must be reported on dshs chik-den-zika supplemental form?

The DSHS Chik-Den-Zika supplemental form requires reporting of demographic information, symptoms, laboratory results, and travel history of the affected individual.