Get the free Zika Interim Surveillance Form

Testing Approved Yes Approved by NEDSS ID No MARYLAND DEPARTMENT OF HEALTH AND MENTAL HYGIENE Zika Virus Interim Surveillance PERSON COMPLETING FORM Date form completed Name Affiliation Phone FAX PATIENT INFORMATION Last First MI DOB Age Sex Street City State and Zip County Place of Work/Occupation Hispanic/Latino Race select all that apply Country of Birth Yes No Unknown American Indian/Alaska Native Native Hawaiian/other PI CLINICAL INFORMATION Date of Symptom Onset Hospitalized Yes...

How to fill out zika interim surveillance form

How to fill out zika interim surveillance form

1. Open the zika interim surveillance form.
2. Read the instructions and guidelines carefully before proceeding.
3. Start by filling out the personal information section, including the name, age, and contact details of the person being reported.
4. Move on to the symptoms section and mark the appropriate checkboxes for any observed symptoms.
5. Provide details about any travel history to areas with known zika virus transmission.
6. Fill in the laboratory test information, including the type of test conducted and the results.
7. Include any additional notes or comments relevant to the case.
8. Double-check the form for any errors or missing information.
9. Submit the completed zika interim surveillance form to the designated authority for further analysis and action.

Who needs zika interim surveillance form?

1. Healthcare professionals involved in zika virus surveillance.
2. Medical practitioners or clinics dealing with potential zika virus cases.
3. Public health departments or agencies responsible for monitoring and prevention of zika virus spread.

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What is zika interim surveillance form?

Zika interim surveillance form is a document used to monitor and track cases of zika virus infection.

Who is required to file zika interim surveillance form?

Healthcare providers and public health officials are required to file zika interim surveillance form.

How to fill out zika interim surveillance form?

To fill out the zika interim surveillance form, healthcare providers need to enter relevant information about suspected or confirmed cases of zika virus infection.

What is the purpose of zika interim surveillance form?

The purpose of zika interim surveillance form is to gather data on zika virus cases for monitoring and control purposes.

What information must be reported on zika interim surveillance form?

Information such as patient demographics, symptoms, travel history, and lab test results must be reported on zika interim surveillance form.