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.

Select Condition

Disease or Condition Date of Onset 

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

Was Patient Hospitalized?Is Case Pregnant?   Outcome
Date Admitted Date Discharged 
Name of HospitalHealth Care Provider
Was Person Treated? Treatment Date  
Treatment

Lab Information


Other Information

Person Reporting Facility TypeOrdering Facility 
Telephone Number 
Cancer SiteDate Cancer DiagnosedCancer Histology
Comments