WA DOH 210-041 2022-2025 free printable template
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Case name (last, first) ___
Birth date ___/___/___Age at symptom onset ___YearsMonthsAlternate name ___PertussisPhone ___
Address typeHomeMailingOtherEmail ___
TemporaryWorkStreet address ___Countywide/State/Zip/County
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How to fill out WA DOH 210-041
01
Download the WA DOH 210-041 form from the Washington State Department of Health website.
02
Carefully read the instructions provided on the first page of the form.
03
Fill out the personal information section, including your name, address, phone number, and date of birth.
04
Provide the required information regarding your health history and any relevant medical conditions.
05
Complete the consent section by signing and dating the form where indicated.
06
If applicable, gather any additional documentation that may be required to accompany the form.
07
Review the form to ensure all sections are completed accurately.
08
Submit the completed form to the appropriate department as instructed, either via mail or electronically.
Who needs WA DOH 210-041?
01
Individuals applying for a medical exemption or those seeking to establish proof of immunization.
02
Parents or guardians completing the form on behalf of minors for school or daycare requirements.
03
Health care providers assisting patients with necessary documentation for immunization records.
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People Also Ask about
What is the period of communicability of pertussis?
When and for how long is a person able to spread pertussis? A person can transmit pertussis from 7 days following exposure to three weeks after the onset of coughing episodes. The period of communicability is reduced to 5 days with antibiotic therapy.
What is the rate of pertussis in Washington state?
The overall year‐to‐date incidence rate is 0.3 pertussis cases per 100,000 Washington residents from weeks 1 through 18, with an incidence rate among infants under one year of age of 2.2 cases per 100,000 (see Table 1). Infants under one year of age are among the most vulnerable to severe pertussis disease.
What is the clinical hallmark of pertussis?
Paroxysms of numerous, rapid coughs due to difficulty expelling thick mucus from the tracheobronchial tree. Long inspiratory effort accompanied by a high-pitched “whoop” at the end of the paroxysms. Cyanosis. Vomiting Exhaustion.
What are the three clinical stages of pertussis?
After an incubation period of 1 to 3 weeks, pertussis infection typically progresses through three distinct stages: the catarrhal phase, the paroxysmal phase, and the convalescent phase.
What are the clinical criteria for pertussis?
A case diagnosed as pertussis by a physician, or a person with a cough lasting ≥2 weeks with ≥1 of the following symptoms: paroxysms (ie, fits) of coughing. inspiratory “whooping” posttussive vomiting (ie, vomiting immediately after coughing) without other apparent cause.
What is a pertussis outbreak?
Whooping cough (pertussis) is an endemic (common) disease in the United States. It is a contagious respiratory illness and spreads easily from person to person. Outbreaks may occur in settings such as schools, child care centers, hospitals, or in large geographic areas.
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What is WA DOH 210-041?
WA DOH 210-041 is a form used by the Washington State Department of Health for reporting specific health-related data.
Who is required to file WA DOH 210-041?
Health care providers, facilities, and organizations that meet certain criteria regarding patient care and reporting requirements are required to file WA DOH 210-041.
How to fill out WA DOH 210-041?
To fill out WA DOH 210-041, complete all required fields accurately and completely, ensuring that all information provided adheres to the guidelines set by the Washington State Department of Health.
What is the purpose of WA DOH 210-041?
The purpose of WA DOH 210-041 is to collect standardized data to monitor public health, track health trends, and ensure compliance with state health regulations.
What information must be reported on WA DOH 210-041?
Information such as patient demographics, treatment details, and any relevant health outcomes must be reported on WA DOH 210-041.
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