Get the free Pertussis Enhanced Surveillance Form - HPSC

Pertussis Enhanced Surveillance Form ID No. HSE Area CCA Patient Name Address Mobile No. Phone No. School/college address Sex: M Work address F Age DOB NK Country of birth Please state whether Months

How to fill out pertussis enhanced surveillance form

How to fill out pertussis enhanced surveillance form:

1. Start by filling out your personal information, such as your name, date of birth, and contact information. This will help identify the person the form is associated with.
2. Next, provide information about your healthcare provider. Include their name, address, and contact information. This will help establish a connection between the form and the medical professional involved.
3. Indicate the date of your visit or encounter related to pertussis. This will help track when the potential exposure or infection occurred.
4. Describe your symptoms and the duration of your illness. Include details such as coughing frequency, severity, and any accompanying symptoms. This will provide valuable information for diagnosis and assessing the severity of the illness.
5. Provide a thorough medical history, including any previous pertussis vaccinations and their dates. This information helps in determining susceptibility and identifying potential risk factors.
6. If applicable, provide information about potential sources of exposure to pertussis. This may include contact with someone diagnosed with pertussis or visiting a location where an outbreak has occurred.
7. Lastly, sign and date the form to certify the accuracy of the provided information.

Who needs pertussis enhanced surveillance form:

1. Individuals who have been diagnosed with pertussis or are suspected to have the disease may need to fill out the pertussis enhanced surveillance form. This includes both confirmed and probable cases.
2. Healthcare providers who come across patients with pertussis-like symptoms should also utilize this form to report cases to the appropriate health agencies.
3. Authorities responsible for monitoring and controlling the spread of pertussis rely on this form to collect data and detect outbreaks. By accurately filling out the form, individuals and healthcare providers contribute to the overall surveillance efforts.

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What is pertussis enhanced surveillance form?

The pertussis enhanced surveillance form is a document used to gather detailed information about suspected or confirmed cases of pertussis in order to monitor and track the disease.

Who is required to file pertussis enhanced surveillance form?

Healthcare providers, healthcare facilities, and public health professionals are required to file the pertussis enhanced surveillance form.

How to fill out pertussis enhanced surveillance form?

The pertussis enhanced surveillance form should be completed with accurate and detailed information about the suspected or confirmed case of pertussis, including symptoms, test results, and demographic data.

What is the purpose of pertussis enhanced surveillance form?

The purpose of the pertussis enhanced surveillance form is to monitor and track cases of pertussis in order to identify outbreaks, inform public health interventions, and prevent the spread of the disease.

What information must be reported on pertussis enhanced surveillance form?

Information such as patient demographics, symptoms, laboratory test results, vaccination history, and contact information must be reported on the pertussis enhanced surveillance form.