North Dakota Morbidity Report

North Dakota Department of Health
Division of Disease Control
Confidentiality Protected by North Dakota Century Codes 23-07-02.1 and 23-07-02.2

*North Dakota Department of Health will follow up on incomplete reports as needed.

Patient Information

Last Name   First Name   Gender
Street Address
City State Zip Code County
Telephone No.
Date of Birth     Race Ethnicity
Name of Employer Business Telephone Marital Status

Clinical Information

Disease or Condition   Date of Onset  
Was Patient Hospitalized? Is Case Pregnant?   Outcome
Date Admitted   Date Discharged  
Name of Hospital Health Care Provider
Was Person Treated? Treatment Date
Treatment

Lab Information

Has Diagnosis Been Confirmed by Laboratory Name of Lab
Specimen Source Date Specimen Collected   Result Date  
Name of Test Result
Was a Sample Submitted to the
ND Public Health Lab?
Specimen Submitted Is
Reason Test Conducted If Other Specify
Is Isolate Resistant to Any
Antimicrobial Agent? *
*If yes please fax a susceptibility report to 701.328.0355

Other Information

Person Reporting Address/Facility  
Telephone Number  
Cancer Site Date Cancer Diagnosed Cancer Histology
Comments