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Typhoid Carrier Agreement Mobile App

The Center for Infectious Diseases, Division of Communicable Disease Control, requires the information within this app and is intended for use by health professionals only. Reportable Diseases and Conditions for specific diseases and conditions are mandated by state laws and regulations to be reported by healthcare providers and laboratories to local health officers. The Typhoid Carrier Agreement mobile app provides an easy to complete paperless version of the mandated case report form specific to Typhoid. The app is filled out using a smartphone or tablet. This GoCanvas app can be made HIPAA compliant and is ideal for Disease Surveillance and Reporting.

The Center for Disease Control, national centers, children’s hospital, public health and local health departments urge health care providers to promptly report infectious diseases as well as virus infections. It is important for patient safety. Pregnant women, immigrant children, illegal immigrants and travelers are at a greater risk for communicable diseases and birth defects from lack of infection control and virus transmission. This app is specific to Typhoid but please don’t hesitate to report any suspicious respiratory illness, flu, rash, pneumonia or virus infection. Timely reporting can stop outbreaks.

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Take a peek inside the Typhoid Carrier Agreement Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    I have been informed that I am a typhoid carrier and that unless precautions are taken, persons m...

  • Ico statictext

    I shall take no part in the preparation, serving, or handling of milk or other food which may be...

  • Ico statictext

    I shall not participate in the management of a dairy or other milk distributing plant, boarding ...

  • Ico statictext

    I shall not engage in any occupation involving the direct care of young children, the elderly, o...

  • Ico statictext

    I shall wash my hands thoroughly with soap and hot water after using the toilet and before handl...

  • Ico statictext

    If flush toilets are not available, I shall dispose of my stool and urine according to the instr...

  • Ico statictext

    I shall report immediately to the local health officer any case of illness suggestive of typhoid...

  • Ico statictext

    I shall inform the local health officer of any contemplated change of address or occupation so t...

  • Ico statictext

    I shall communicate with the local health officer before submitting to any type of treatment int...

  • Ico statictext

    I shall notify any physician, hospital, or other institution providing medical care to me, of my...

  • Ico statictext

    The health officer may inform any physician, hospital, or other institution providing my medical...

  • Ico statictext

    I understand that this information is confidential and will not be divulged unless I violate the ...

  • Ico textbox

    Name of typhoid carrier

  • Ico signature

    Signature of typhoid carrier

  • Ico multiline

    Address

  • Ico statictext

    Witnesses:

  • Ico textbox

    Name of witness

  • Ico signature

    Signature

  • Ico date

    Date

  • Ico textbox

    Name of witness

  • Ico signature

    Signature

  • Ico date

    Date

  • ...and More!

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