Guilford County Department of Health and Human Services

Public Health Division

Confidential Communicable Disease Report

Submitter Information

Submitter Email Address

Initial Date of Report to Public Health

Entity Information

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Other Heatlh Care Provider

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Long Term Care Provider

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Is this a report for Covid? Value is not selected

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Covid Symptom Onset Date

CDC Covid Guidelines

(Updated June 2024)

Stay home and away from others for at least 24 hours until both are true

Your symptoms are getting better overall, and
You have not had a fever (and are not using fever-reducing medication)
If you return to normal activities and your symptoms return or you develop fever stay at home and away from others again for 24 hours until both of the above are true

For more information from the CDC please visit the link below:

https://www.cdc.gov/respiratory-viruses/prevention/precautions-when-sick.html

Report to your internal agency occupational healthcare provider

For more information from the CDC please visit the link below:

https://www.cdc.gov/covid/hcp/infection-control/?CDC_AAref_Val=https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html

Stay home and away from others untill ALL THREE below are met:

•   At least 10 days have passed since symptoms first appeared
•   At least 24 hours have passed since last fever without the use of fever-reducing medications
•   Symptoms (e.g., cough, shortness of breath) have improved

For more information from the CDC please visit the link below:

https://www.cdc.gov/covid/hcp/infection-control/?CDC_AAref_Val=https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html

Patient Information

Patient's First Name

Patient's Last Name

Patient's Middle Name

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Patient's Maiden Other

Alias

Birthdate

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Parent or Guardian

Medical Record Number

Address

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City

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Zip

County

Phone

Age

Race (check all that apply) Values are not selected

Ethnic Origin Value is not selected

Was patient hospitalized for this disease? (>24) Value is not selected

Hospitalization Date

Did patient die from this disease? Value is not selected

Is the patient pregnant? Value is not selected

Patient is associated with (check all that apply) Values are not selected

In what geographic location was the patient MOST LIKELY exposed? Value is not selected

Clinical Information

Is/was patient symptomatic for this disease? Value is not selected

If yes, symptom onset date

Date of Test

Outbreak/Cluster Information

Is the patient part of an outbreak/cluster of this disease? Value is not selected

Outbreak/cluster setting Value is not selected

Name of Facility for Outbreak/Cluster

Address of Facility for Outbreak/Cluster

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Patient Full Name

Entity Name

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Public Health - Communicable Disease

Submitter Information

Entity Information

Patient Information

Clinical Information

Outbreak/Cluster Information

Line List Uploads for Long Term Care Facilites