Electronic Communicable Disease Report

CONFIDENTIAL DISEASE REPORTING FORM
*Asterisk indicates a required field.
THIS ONLINE FORM IS TO BE USED FOR THE REPORTING OF HEPATITIS B, HEPATITIS C, AND REPORTABLE STD INCIDENCE ONLY (Syphilis, Chlamydia and Gonorrhea). ALL OTHER REPORTABLE DISEASE INCIDENCE SHOULD BE REPORTED VIA SECURE REPORTING FAX (307-777-5573) OR AS INDICATED ON THE LIST OF REPORTABLE DISEASES AND CONDITIONS WHICH CAN BE FOUND AT http://health.wyo.gov/phsd/epiid/reporting.html, ALONG WITH PRINTABLE REPORTING FORMS. IF YOU HAVE AN URGENT CASE TO REPORT PLEASE CALL THE WYOMING DEPARTMENT OF HEALTH, CIDDC PRIOR TO SUBMISSION FOR ADDITIONAL GUIDANCE.
In order to continue, please read the linked statutory authority statement (click here) and place a checkmark in the box below as acknowledgement of understanding and agreement.
Reporting Facility Validation Number
*   Please call State of Wyoming, Department of Health, CIDDC 307-777-7953 for validation PIN number prior to submission.
 
Patient Information
*   *     *
DOB*      
     
  *    
       
 
Demographics
*   *   *  
 
   
   
 
Provider Information
Select appropriate Health Care Provider from the drop down list. Additional Provider Information (address, phone, etc.) will self-populate - do not change self populated information. If provider is not found or is unknown, please select 'NEW PROVIDER.' Type any known provider information (such as specialty, title, clinic, address, phone, etc) or 'PROVIDER UNKNOWN' into the OTHER NOTES text box at the bottom of this page.
 
*
 
Lab Information
Select appropriate Laboratory from the drop down list. Additional Lab Information (address, phone, etc.) will self-populate - do not change self-populated information. If lab is not found or is unknown, select 'NEW LAB.' Type any known lab information (address, phone, etc) or 'LAB UNKNOWN' into the OTHER NOTES text box at the bottom of this page. IF NO SPECIMEN WAS COLLECTED, SKIP TO SPECIMEN SECTION AND CHOSE 'NO' IN THE 'SPECIMEN COLLECTED' BOX BELOW.
 
*
 
Specimen
Select 'No' if no specimen was collected. Required entries (Collection Date, etc.) will no longer appear.
 
             
Specimen Source   Collection Date *   Result Date *  
 
Diseases
*
   
 
 
 
Patient Treatment
Select the type of disease to generate a list of standard treatments. If the treatment is not on the standard treatment list, leave the 'Treatment' dropdown unselected and enter treatment description in the 'Other Treatment Details' textbox.
 
Select Standard Treatments For:
Treatment
Exam Date Date Treated
Other Treatment
Other Treatment Details (if any)
Partner Treatment
Other Notes