The Virginia Epi 1 form is a crucial document used for reporting diseases and conditions of public health importance to local health departments. It helps ensure timely communication and response to health threats. Understanding how to complete this form accurately can significantly impact public health efforts in Virginia.
The Virginia Epi 1 form is a crucial document for reporting various diseases and conditions that may impact public health. Designed for healthcare providers, it ensures that critical health information is communicated efficiently to local health departments. The form collects essential details about the patient, including their name, date of birth, and contact information, as well as specifics about the disease or condition being reported. It also requires information about the physician and the laboratory involved in the diagnosis. Certain diseases, such as influenza and HIV, must be reported immediately, while others can be reported within a few days. This form serves as a vital tool in monitoring and controlling outbreaks, ensuring that public health officials can respond swiftly to protect the community. Completing the Epi 1 form accurately is important, as it helps track the spread of diseases and informs public health strategies. By following the guidelines outlined in the form, healthcare providers play a key role in safeguarding public health in Virginia.
MAIL THE TOP TWO COPIES TO YOUR LOCAL HEALTH DEPARTMENT
VIRGINIA DEPARTMENT OF HEALTH
Confidential Morbidity Report
Patient's Name (Last, First, Middle Initial):
SSN: ___________-__________-____________
Home #: ( ) _________-___________
Patient's Address (Street, City or Town, State, Zip Code):
Work #: ( ) _________-___________
City or County of Residence
Date of Birth:
Age:
Race: American Indian/Alaskan Native
Asian
Hispanic:
Sex:
(mm/dd/yyyy)
Black/African American
Hawaiian/Pacific Islander
Yes
F
White
Unknown
No
M
DISEASE OR CONDITION:
Pregnant:
Death: Yes
Death Date:
Date of Onset:
Date of Diagnosis:
Influenza: (Report # and type only. No patient identification)
Number of Cases:
Type, if Known:
Physician's Name:
Phone #: (
) _________-___________
Address:
Hospital Admission:
Hospital Name:
Date of Admission:
Medical Record Number:
Laboratory Information and Results
Source of Specimen:
Laboratory Test(s) and Finding(s):
Date Collected:
Name/Address of Lab:
CLIA Number:
Other Information
Comments: (e.g., Risk situation [food handling, patient care, day care], Treatment [including dates], Immunization status [including dates], Signs/Symptoms, Exposure, Outbreak-associated, etc.)
Name, Address, and Phone Number of Person Completing this Form:
Date Reported:
Check here if you need more of these forms, or call your local health department.
(Be sure your address is complete.)
For Health Department Use
Date Received:
VEDSS Patient ID:
Please complete as much of this form as possible
Form Epi-1, 10/2011
Please report the following diseases (and any other disease or outbreak of public health importance) in the manner required by Sections 32.1-36 and 32.1-37 of the Code of Virginia and 12 VAC 5-90-80 and 12 VAC 5- 90-90 of the Board of Health Regulations for Disease Reporting and Control. Enter as much information as possible on the reporting form.
Acquired immunodeficiency syndrome (AIDS) Amebiasis *
ANTHRAX *
Arboviral infection (e.g., dengue, EEE, LAC, SLE, WNV) *
BOTULISM * BRUCELLOSIS * Campylobacteriosis * Chancroid * Chickenpox (Varicella) * Chlamydia trachomatis infection *
CHOLERA *
Creutzfeldt-Jakob disease if <55 years of age * Cryptosporidiosis *
Cyclosporiasis *
DIPHTHERIA *
DISEASE CAUSED BY AN AGENT THAT MAY HAVE BEEN USED AS A WEAPON
Ehrlichiosis/Anaplasmosis *
Escherichia coli infection, Shiga toxin-producing * ^ Giardiasis *
Gonorrhea * Granuloma inguinale
HAEMOPHILUS INFLUENZAE INFECTION, INVASIVE * Hantavirus pulmonary syndrome *
Hemolytic uremic syndrome (HUS)
HEPATITIS A *
Hepatitis B (acute and chronic) * Hepatitis C (acute and chronic) * Hepatitis, other acute viral
Human immunodeficiency virus (HIV) infection * Influenza * #
(report INFLUENZA A, NOVEL VIRUS immediately)
INFLUENZA-ASSOCIATED DEATHS IN CHILDREN <18 YEARS OF AGE
Lead, elevated blood levels * Legionellosis *
Leprosy (Hansen disease) Listeriosis *
Lyme disease * Lymphogranuloma venereum Malaria *
MEASLES (RUBEOLA) * MENINGOCOCCAL DISEASE *
MONKEYPOX * Mumps *
MYCOBACTERIAL DISEASES (INCLUDING AFB),
(IDENTIFICATION OF ORGANISM) AND DRUG SUSCEPTIBILITY
Ophthalmia neonatorum
OUTBREAKS, ALL (including, but not limited to, foodborne, healthcare-associated, occupational, toxic substance-related and waterborne)
PERTUSSIS * PLAGUE *
POLIOVIRUS INFECTION, INCLUDING POLIOMYELITIS * PSITTACOSIS *
Q FEVER *
RABIES, HUMAN AND ANIMAL * Rabies treatment, post-exposure
RUBELLA, INCLUDING CONGENITAL RUBELLA SYNDROME * Salmonellosis *
SEVERE ACUTE RESPIRATORY SYNDROME (SARS) * Shigellosis *
SMALLPOX (VARIOLA) * Spotted fever rickettsiosis * Staphylococcus aureus infection
invasive methicillin-resistant (MRSA) * and vancomycin-intermediate or vancomycin-resistant *
Streptococcal disease, Group A, invasive or toxic shock * Streptococcus pneumoniae infection, invasive, in children <5 years
of age *
Syphilis (report PRIMARY and SECONDARY immediately) * Tetanus
Toxic substance-related illness * Trichinosis (Trichinellosis) *
TUBERCULOSIS (TB), ACTIVE DISEASE * Tuberculosis infection in children <4 years of age
TULAREMIA * TYPHOID/PARATYPHOID FEVER * UNUSUAL OCCURRENCE OF DISEASE OF
PUBLIC HEALTH CONCERN VACCINIA, DISEASE OR ADVERSE EVENT * VIBRIO INFECTION *
VIRAL HEMORRHAGIC FEVER * YELLOW FEVER *
Yersiniosis *
Report all conditions to your local health department when suspected or confirmed. Those in UPPER CASE must be reported immediately by the most rapid means available. All others must be reported within 3 days.
*These conditions are reportable by directors of laboratories. In addition, these and all other conditions except mycobacterial disease (other than TB) and invasive MRSA infection are reportable by physicians and directors of medical care facilities. Reports may be by computer- generated printout, Epi-1 form, CDC surveillance form, or upon agreement with VDH, by means of secure electronic transmission.
A laboratory identifying evidence of these conditions shall notify the health department of the positive culture and submit the initial isolate to the Virginia Division of Consolidated Laboratory Services (DCLS) or, for TB, to DCLS or other laboratory designated by the Board.
^Laboratories that use a Shiga toxin EIA methodology but do not perform simultaneous culture for Shiga toxin-producing E. coli should forward all positive stool specimens or positive enrichment broths to DCLS for confirmation and further characterization.
#Physicians and directors of medical care facilities should report influenza by number of cases only (report total number per week and by type of influenza, if known); however, individual cases of influenza A novel virus must be reported immediately by the most rapid means available.
Note: 1. Some healthcare-associated infections are reportable. Contact the VDH Healthcare-Associated Infections Program at (804) 864-8141 or see 12 VAC 5-90-370 for more information.
2.Cancers are also reportable. Contact the VDH Virginia Cancer Registry at (804) 864-7866 or see 12 VAC 5-90-150-180 for more information.
Virginia Department of Health
Office of Epidemiology
P.O. Box 2448, Suite 516-East Richmond, Virginia 23218-2448
Virginia Wic Formula List 2023 - It serves as a direct communication tool between healthcare providers and the Virginia WIC program, facilitating the provision of specialized dietary care to participants.
For those looking to simplify their transaction processes, the Georgia Bill of Sale form can be easily obtained through platforms like PDF Templates Online, ensuring that both buyers and sellers have access to the necessary documentation to formalize their agreements and protect their interests.
Virginia Department of Motor Vehicles Fotos - The form's emphasis on accurate and timely updates reflects Virginia's commitment to road safety and legal adherence among all drivers.
Pdf:zz1-1g-wv3c= Divorce Papers - Advice from the Fairfax County Circuit Court on the critical steps and legal considerations for anyone filing for divorce without an attorney.