USVI Public Records

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Revised: October 2012 Virgin Islands Department of Health Notification of Infectious Disease Form Island: St. Croix [ ] St. Thomas [ ] St. John [ ] Source of Information: □Private Physician □Clinic: (name) _____________________ □Private Laboratory: (name)_________________ □ School (name):______________________ □Hospital: Location in Hospital (e.g. ER, Laboratory etc)_______________________________ Admitted to Hospital: YES [ ] NO [ ] / Date Admitted:_______________ Discharged_______________ Demographic Information: RACE: □ Black □White □Asian or Pacific Islander □ American Indian or Alaskan Native ETHNICITY: □ Hispanic □ Non-Hispanic □Unknown PATIENT’S NAME:____________________________________ TODAY’S DATE:__________ ______ DATE OF BIRTH: MONTH______ DAY____ YEAR_______ SEX M_____ F_____ PATIENT’S ADDRESS_____________________________________________________________________ PATIENT’S PHONE#___________________ PARENT/GUARDIAN ________________________ CONTACT PHONE#_____________________ PHYSICIAN’S NAME__________________ OFFICE ADDRESS_________________________________ PHONE:_______________________________ All of the following diseases, if diagnosed or suspected, must be reported to the Virgin Islands Department of Health. All require PROMPT notification, but they have been divided into three categories based on their level of public health risk. On the back of this form, please indicate whether you are reporting a suspected or confirmed case of disease. A. These diseases carry a SERIOUS PUBLIC HEALTH RISK. Make an IMMEDIATE telephone report to the Virgin Islands Department of Health at 773-1311, Ext. 3241 then submit this completed form IMMEDIATELY by Fax to 713-1508. If you cannot fax this form it should be delivered to the Department of Health on the appropriate island. In the event that an immediate report is required after regular working hours, please call 340-626-1654. See the back of this form for the delivery addresses. ________________________________________________________________________________________ □ Anthrax □ Measles □ Smallpox □ Botulism □ Meningitis □ Severe Acute Respiratory Syndrome (SARS) □ Brucellosis □ Pertussis □ Tuberculosis □ Cholera □ Poliomyelitis □ Tularemia □ Diptheria □ Plague □ Typhoid □ Encephalitis □ Q Fever □ Typhus □ Enterohemorrhagic E. Coli (0157) □ Rabies □ Yellow Fever □ Legionaires □ Rubella □ Dengue (with hemorrhagic features) PLEASE TURN TO THE REVERSE SIDE FOR ADDITIONAL DISEASE REPORTING B. These diseases carry SIGNIFICANT PUBLIC HEALTH RISK. They should be reported within 48 hours to the Virgin Islands Department of Health. A completed copy of this form must be faxed to 713-1508. If you cannot fax this form it should be delivered (within 48 hours) to the Department of Health on the appropriate island. A telephone report to 773-1311 extension 3241 or 3007 is only required for those diseases indicated by the (*). □ Chancroid □ Hansen’s Disease* □ Malaria* □ Chlamydia □ Hanta Virus Pulmonary Syndrome* □ Psittacosis □ Ciguatera □ Hemolytic Uremic Syndrome □ Syphilis* □ Dengue □ Hepatitis A* □ Streptococcus Pneumonia (drug resistant) □ Ehrlichiosis □ Hepatitis B □ Staph. Aureus (drug resistant) □ Gonorrhea □ Hepatitis C □ Trichinosis □ Granuloma Inguinale □ HIV/AIDS □Vancomycin Resistant-□ Staph □ Enterococcus □ Invasive Streptococcus A □ Lymphogranuloma □ West Nile Virus* ________________________________________________________________________________________ C. These diseases are to be reported promptly to the Virgin Islands Department of Health using this form. A telephone report is not required. This form should be faxed to 713-1508 or hand delivered to the specified address (below) for the Department of Health on the appropriate island. □ Amebic Dysentery □ Giardia □ Shigellosis □ Chickenpox □ Influenza □ Toxic Shock Syndrome □ Coccidioidomycosis □ Listeriosis □ Tetanus □ Cryptosporidiosis □ Mumps □ Childhood Diabetes Mellitus (age < 20) □ Cyclosporiasis □ Salmonellosis □ Other ______________________________ BRIEF CASE REPORT What is the diagnosis status of this disease? □ Suspected case □ Confirmed case Notable Clinical Symptoms?________________________________________________________________ Notable Physical Findings?__________________________________________________________________ Laboratory Results (confirmatory tests if available) Date_____/_____/____ Test_____________________________ Result_____________________ Date_____/_____/____ Test_____________________________ Result_____________________ Date_____/_____/____ Test_____________________________ Result_____________________ Was treatment prescribed? □Yes □ No Prescribed Medication Regimen___________________________________________________________________ ________________________ ___________________ __________________ Reporting Person’s Signature Reporting Person’s Title Date WHERE TO DELIVER NOTIFICATION FORMS All Reports other than HIV should be delivered on St. Croix to the Office of the Commissioner of Health, Charles Harwood Hospital Complex, 3500 Richmond, Christiansted, and St. Croix VI 00820. On St. Thomas, all reports other than HIV should be sent to the Office of the Commissioner of Health, Roy Lester Schneider Hospital, 48 Sugar Estate, St. Thomas, and USVI 00802. Reports should be addressed to: Dr. Thomas Morris. HIV Reports should be forwarded to the HIV/STD Program Charles Harwood Hospital Complex on St. Croix and to the HIV/STD Program, Knud Hansen Complex, Fax 776-5466, on St. Thomas. ________________________________________________________________________________________________ PLEASE NOTE: THE REPORTING OF NOTIFIABLE DISEASES TO THE DEPARTMENT OF HEALTH IS REQUIRED BY LAW IN THE U. S. VIRGIN ISLANDS. Fulfilling this requirement will by no means negate your responsibility to report similar information to other agencies or programs with which you have collaborative agreements.