Sexually transmitted diseases laboratory & morbidity epidemiologic case report, f-44243

DEPARTMENT OF HEALTH
SEXUALLY TRANSIMITTED DISEASES
STATE OF WISCONSIN
SERVICES
LABORATORY & MORBIDITY EPIDEMIOLOGIC
s. 252.05 Wisconsin Statss
(608) 266-7365
CASE REPORT
Additional information for completing on page 2 A. PATIENT – Demographic Information
Last Name

B. DISEASE CLASSIFICATION RELATED TO DIAGNOSIS
Salpingitis – Pelvic Inflammatory Disease (PID) Early Latent (no symptoms < 1 yr duration) Uncomp. Urogenital (urethritis, cervicitis) Late Latent (no symptoms > 1 yr duration) C. LABORATORY TEST(S) RELATED TO CURRENT DIAGNOSIS
Attending Physician / Provider Ordering Test

Name of Laboratory Performing Test(s)
D. TREATMENT (RX) INFORMATION
Benzathine penicillin G 2.4 m.u. IM x 1 Benzathine penicillin G 2.4 m.u. IM x 3 Local Health Departments ONLY – Fax to: (608) 261-9301 Copy A (White) – State Epidemiologist
F-44243 (Rev. 12/08)
Information for Completing
Sexually Transmitted Diseases Laboratory and Morbidity Epidemiologic Case Report
Information reported on this form is authorized by Wisconsin Statute 252.11. All information contained in this report is confidential except as may be needed for the purpose of investigation, control and prevention of communicable diseases. General Instructions
This STD case report form is to be used by: laboratories, physicians, hospitals, STD clinics and, Local Health Departments (LHDs) or other
agencies within the state of Wisconsin to report suspected or confirmed Sexually Transmitted Diseases. This report is mandated under the
provisions of section 252.11 of the Wisconsin Statutes. As specified in rules promulgated by the department, ALL information (Laboratory and
Morbidity) is to be reported to the Local Health Department / Officer in the county that the patient resides within 72 hours and Local Health
Departments need to report to the Wisconsin Department of Health Services weekly.
Retention and Distribution
Copy A (white) to be submitted to the State Epidemiologist by the Local Health Department (LHD) / Officer.
Copy B (yellow) retained by the LHD / Officer.
Copy C (green) retained in Patient Medical Records and by Attending Physician.
Copy D (pink) retained by Laboratory reporting the positive test result(s).
This form is also available as an MS Word fillable format available in the DHS Forms Index.
If you use the electronic copy from the website, please make 3 additional copies and distribute as listed above.
Reportable Sexually Transmitted Diseases (as of 03/01/2008)
Sexually Transmitted Pelvic Inflammatory Disease (PID) Specific Instructions
SECTION A: Patient Demographic Information: Complete ALL patient information. For date of birth use month, day, and year (e.g. 01-01-
2008). Do not omit any demographic information. Include a complete mailing address, city, county, state, zip code and telephone number.
When reporting STDs for females make sure to note pregnancy status and number of weeks pregnant.
SECTION B: Disease Classification Related to Diagnosis: Check box for each disease suspected or confirmed. See CDC treatment
guidelines for additional case classification information. To report PID associated with Chlamydia (CT) or Gonorrhea (GC), check box(es) in
disease and salpingitis.
SECTION C: Laboratory Test(s) Related to Diagnosis: Use a single line to report information on each test. There is enough space to report
four results on each case report form. If reporting more than four positive tests on the same individual, use an additional form and attach it to the
original form.
Test Type(s): Indicate the type of test used to confirm diagnosis. Example: (GC-LCR, CT-EIA, GC-AMA VDRL, FTA-ABS)
Specimen source: Indicate anatomical specimen collection site. Example: (Cervix, urethra, blood, or urine)

SECTION D: Treatment (Rx) Information: Check all Rx related to this case report. If reporting other Rx, follow Rx format used on this form.
Include the Name (doxy., ceft., etc.), Type (PO, IM, BID), Amount given (100mg, 2.4 m.u. etc.) and number of days (x 1 d, x 7 d etc.) provided.
Provide complete information on Treating/Attending physician. Use month, day, and year (e.g. 01-01-2008) for date treated, date onset of
symptoms, and date reported to Local Health Officer.
See the current CDC Sexually Transmitted Diseases Treatment Guidelines, found at:

Indicate the name, title, telephone number and mailing address for the individual completing the report so that program staff may contact the
individual completing the form, or the attending physician if there are questions regarding the case report.
Mailing instructions: Providers mail completed form(s) within 72 hours to Local Health Departments in the county that the patient resides.
Local health department addresses can be found at:
Local Health Departments enter information into WEDSS or mail completed form(s) to the following address weekly:
Department of Health Services
Division of Public Health – Rm. 318
Attention: Sexually Transmitted Disease (STD) Section
PO Box 2659
Madison WI 53701-2659
Fax to: 608-261-9301

Partner referral/interview: Use the CDC Field Record form (73.2936S) to document information on sex partners, suspects and associates.
When a named partner, suspect or associate resides outside of the initiating agency’s jurisdiction (disposition=K), a Field Record form should be
completed and routed to the appropriate LHD for epidemiologic follow-up, or to the Division of Public Health address above if out of state.

Source: http://www.de-pere.org/egov/documents/1300716974_118469.pdf