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Confidential Report of Communicable Disease Form

Part 1 of the Confidential Report of Communicable Disease form is used by health care providers and local health department staff to report and investigate diseases that represent a public health threat according to 10A NCAC 41A.0101 Reportable Diseases and Conditions. Local health department contact information is contained on page one, in the upper right corner. Once completed by the provider, this form should be returned by FAX to Guilford County Department of Public Health to the attention of the staff person listed.

If you are reporting one of the following sexually transmitted infections, please use the  NC Electronic Disease Surveillance Form (STI) return it to the contact person.

Syphilis   (See List, page 2)
Gonorrhea   (300)
Chlamydia   (200)
Chancroid   (100)
Granuloma inguinale   (500)
Lyphogranuloma venereum   (600)
Ophthalmia neonatorium   (345)

If you are a physician reporting a positive HIV or AIDS case, please use the Adult HIV Report Form.  Upon completion of this form, fax it to:  336-641-5777.

HIV   (900)
AIDS   (950)
If you are reporting any other communicable disease, please use the form below and return it to the contact person.

NC Electronic Disease Surveillance Form (other communicable diseases)