Required Information When Reporting
Patient information
Full name, address, telephone number, date of birth, gender, and race/ethnicity.
Disease information
Disease being reported, date of onset, hospitalization status and date of admission, and pregnancy status and estimated due date.
Diagnostic information
Name, address, and telephone number of the diagnostic facility (where the case sought care), and the full name, address, and telephone number of the healthcare provider.
Reporter information
Full name of the person reporting the case, the name of the facility reporting, and the telephone number of the person or facility.
Laboratory information
Name of the laboratory performing the test, laboratory’s name for the test, specimen source, specimen collection date, testing results, test reference range, and test status (preliminary, final, amended and/or corrected).