Date: ____________________

Dear Health Care Professional,

Hepatitis C is a reportable disease under N.J. A. C. 8:57. To determine if this is a confirmed case, we need to obtain additional information. Attached is a copy of the hepatitis C blood work for your patient, ___________________________________

Please provide the following information:

Date of Diagnosis:

Date of Onset (if known):

Race:

White	Asian

American Indian	Black

Native Hawaiian	Ethnicity:

Other/Unknown

Hispanic/Latino

Non-Hispanic or non-Latino
Type (Check one)

ACUTE or CHRONIC
Please check any known risk factors:

Past or present injection drug use	Long term dialysis

Blood transfusion prior to 1992	Multiple sexual partners

Received clotting factor prior to 1987	Incarceration

Tattoos or body piercing	Other healthcare procedure (specify):

Organ transplant prior to 1992	___________________________________

Health Care Worker/Military Medic	Unknown
Patient informed of diagnosis?

Yes No	Disease-related education provided to patient?

Yes No

Thank you for your assistance. Please fax to the _________________________ Health Department at _________________________.

______________________________________

(your name)

CDS-17a

AUG 06

cds-17a, hepatitis investigation letter, (short)

cds-17a, hepatitis, investigation

EWHITE

2006-07-18

njdhsS