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Practitioner Disease Report Form 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 Practitioner Disease Report Form mobile app provides an easy to complete paperless version of the mandated case report form specific to all Communicable Diseases. 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 all Communicable Diseases but please don’t hesitate to report any suspicious respiratory illness, flu, rash, pneumonia or virus infection. Timely reporting can stop outbreaks.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Practitioner Disease Report Form Mobile App

Included Features

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Included Fields

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

  • Ico textbox

    SSN:

  • Ico textbox

    Last name:

  • Ico textbox

    First name:

  • Ico textbox

    Middle:

  • Ico textbox

    Parent name:

  • Ico dropdown

    Gender:

  • Ico dropdown

    Pregnant:

  • Ico date

    Birth date:

  • Ico date

    Death date:

  • Ico dropdown

    Race:

  • Ico dropdown

    Ethnicity:

  • Ico textbox

    Address:

  • Ico integer

    ZIP:

  • Ico textbox

    County:

  • Ico textbox

    City:

  • Ico dropdown

    State

  • Ico textbox

    Home phone:

  • Ico textbox

    Other phone:

  • Ico textbox

    Emer.

  • Ico textbox

    Email:

  • Ico textbox

    MRN:

  • Ico date

    Date onset:

  • Ico date

    Date diagnosis:

  • Ico dropdown

    Died:

  • Ico dropdown

    Hospitalized:

  • Ico textbox

    Hospital name:

  • Ico date

    Date admitted:

  • Ico date

    Date discharged:

  • ...and More!

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