Get the free Salmonellosis Case Report Form - PHPA

Initials NE DSS Patient ID: Salmonellosis Case Report Form Investigation ID: CAS Maryland Department of Health & Mental Hygiene Reporting Source: Report Date: / / County Rec d Date: / / General Instructions

How to fill out salmonellosis case report form

How to fill out a salmonellosis case report form:

1. Begin by filling out the basic information section of the form. This includes the name and contact information of the person completing the form, as well as the date and time of the report.
2. Provide the details of the person who is suspected or confirmed to have salmonellosis. This includes their name, age, gender, and any other relevant demographics. Additionally, include their contact information and any known medical conditions or risk factors.
3. Describe the symptoms experienced by the affected individual. This may include information about fever, diarrhea, vomiting, abdominal pain, and any other relevant signs or symptoms. Be as specific and detailed as possible.
4. Indicate the date and time of symptom onset, as well as any relevant dates of hospitalization or medical treatment received. Include information about the healthcare facility or provider involved, if applicable.
5. Provide a brief summary of the patient's medical history, including any pre-existing conditions or medications they may be taking. This information can help identify potential risk factors or sources of infection.
6. Describe any potential sources of exposure to salmonella. This may include information about recent travel, consumption of high-risk foods (such as undercooked poultry or raw eggs), contact with animals, or exposure to contaminated environments.
7. If the case has been confirmed through laboratory testing, include the details of the testing facility, method used, and any relevant test results or reports. This helps to establish the accuracy and credibility of the diagnosis.
8. In the final section, provide any additional information or comments that may be relevant to the case. This can include information about contact tracing efforts, potential outbreaks, or any other relevant details that may assist in the investigation and prevention of further cases.

Who needs a salmonellosis case report form:

Salmonellosis case report forms are typically required by public health agencies, healthcare providers, and laboratories.

1. Public health agencies use these forms to track and monitor the incidence of salmonellosis within a community or region. This data helps identify outbreaks, assess the effectiveness of preventive measures, and determine any necessary public health interventions.
2. Healthcare providers use the forms to report individual cases of salmonellosis to the appropriate public health authorities. This allows for prompt investigation and follow-up to prevent further transmission and provide appropriate treatment to affected individuals.
3. Laboratories use the forms to report positive salmonella test results to public health agencies. This information is crucial for surveillance purposes and helps identify any emerging trends or patterns in salmonella infections.

Overall, salmonellosis case report forms play a vital role in the surveillance, prevention, and control of this infectious disease.

For pdfFiller’s FAQs

What is salmonellosis case report form?

Salmonellosis case report form is a document used to report cases of salmonellosis, a foodborne illness caused by the Salmonella bacteria.

Who is required to file salmonellosis case report form?

Healthcare providers, laboratories, and public health officials are required to file salmonellosis case report form.

How to fill out salmonellosis case report form?

The form should be filled out with detailed information about the patient's symptoms, medical history, and possible sources of exposure to Salmonella bacteria.

What is the purpose of salmonellosis case report form?

The purpose of the form is to track and investigate cases of salmonellosis in order to prevent further spread of the illness.

What information must be reported on salmonellosis case report form?

Information such as patient's name, age, symptoms, medical history, laboratory test results, and possible sources of exposure to Salmonella bacteria must be reported on the form.

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