ࡱ> qsp#` :bjbj5G5G d]W-W-} 2...8.D/L2@L$n/n////y=y=y=wKyKyKyKyKyKyK$dMhOK]]>:y=]>]>K//? KAAA]>j//wKA]>wKAA A/b/ "O.>AwKL0@LAPm?HPAAPDy="=A==y=y=y=KK@^y=y=y=@L]>]>]>]>222d)222)222 Utah Public Health Name of Local Health Department Address of Local Health Department Phone: (801) xxx-xxxx Confidential Fax (801) xxx-xxxx May 15, 2008            TETANUS Patient name: ______________________________ ID: ___________ Lock-jaw -  PAGE 2 - DEMOGRAPHIC INFORMATION Parent/guardian name: Relationship: REPORTING UDOH Case classification: % Confirmed % Probable % Suspect % Pending % Out of state % Not a case Was patient hospitalized? Y N U Hospital: Date of admission: _____/_____/_____ to _____/_____/_____ Medical record #: Onset Date: _____/_____/_____ Clinician Name: Clinician Phone #: Address: City: State: County: Zip: Date of birth: _____/_____/_____ Age: Phone #1: Phone #2: Phone #3: Gender: (Circle one) Race: (Check all that apply) M F % White % Black/Af. Am % American Indian % Unknown % Asian % Alaskan Native % Native Hawaiian or Pacific Islander LHD Case classification: (Check one) % Confirmed % Probable % Suspect % Pending % Out of state % Not a case CLINICAL INFORMATION Did patient die? Y N U Date of death: _____/_____/_____ Reported by: (Check all that apply) % Hospital/ICP % Clinic/doctor s office % Lab % General public % Other _____________ What is the date the lab reported to the clinician? _____/_____/_____ Reporter s name: _______________________________ Phone number: _______________________________ Reporters agency: ______________________________ Date reported to public health: _____/_____/_____ LHD Reviewer: Patients occupation: LHD Investigator: Phone: Date submitted to UDOH: _____/_____/_____ CONFIDENTIAL CASE REPORT TETANUS Lock-jaw Vaccination history Was patient vaccinated prior to injury? Y N U If yes, list number of doses _________ Date of last vaccination _____/_____/_____ W]^lopŻɻwfWfP@jh"UaJmHnHu ha56jha6UmHnHu jha56UmHnHu jhSo 56UmHnHu hL56.jhyha56CJUaJmHnHu hx6 h56hRh6hRh56hR h6hRh5CJaJhRhj5CJaJhRh5CJaJjhUmHnHu4W d$gdx d$gdEgdVf : 4 C D M N O P Q S 谨{mieahhwhahaha56CJaJhTfHq hT5CJaJhaha5CJaJhnhTh+\jh+\U h1IaJ h44hLhhL56 jht?56UmHnHujht?UaJmHnHu hL56 jhrC56UmHnHu$ d$gdBe d$gdED M N O P Q ` a b $a$gd gda $ d$a$gd44 d$gdES T Z [ \ ] a b c d e f ~     . 0 B D V X t v żŒ󎊎zzzzzsl h[Fha h5Ch[F hQNAhrChrC hrC6h[Fhch$U)h$U)aJ*h$U)5@B*CJOJQJ^JaJph h)h(h(hh$U)aJ0h#Oh$U)5@B*CJOJQJ^JaJphh+\hnhThxmHnHuhjhU(b c d e f ~  j gdt?`gdrCgd[Fgd(gd]` $a$gd]` gd$U)$a$gd$U) > h ( * , . j l n & ( * , < T ` b »ԵԦԌzԌsksfbfbh*g\ h*g\6h6h*g\6 h*g\6aJhKhvaJhwh*g\aJ h*g\aJhfFhvaJhfF hm!hfF hfFaJhhvaJ hvaJ hfFh06 hkUHh@%r hm!h@%rh@%rh ht?h@%r hBTht?h6fht?fHq  hKht?ht?& * , . l n ( * , nvxz|~`gd69Ugd69Ugd*g\gdvgdfFgd@%r "$FH"$68TVt&(*.HҾҾҾҾҾҾڨڂ{tpht? hfFhf h'j%hfFhfFhhSo aJ0h#OhSo 5@B*CJOJQJ^JaJph*hSo 5@B*CJOJQJ^JaJph hQNAh69Uh(=h69U6 h69U6h69Uhahh*g\haJh&;h*g\aJ h*g\aJh*g\ h*g\6,(*,.x"$:gd69Ugd[Fdhgdt? ^`gdt?`gdt?gdt?gdfFgdSo $a$gdSo Ht:k&?ELMUV[nosѿƪўѕ~pf^ZVRVhghNh=ih &zh=i;h &zh=i5;h>bhkL56CJ aJ h>bhy56CJ aJ hy5CJ aJ hkL5CJ aJ heghy5CJaJ h'h69U h)hSo he,hSo h@ZhSo h' hh69Uh hth69Uh69U htht?h6fht?fHq ht? ht?6  !"#$%&8?@ABCDEMVW$a$gdkL$a$gdygdtWGgd'gdSo WXYZ[oR45566 6"6$6666666666`gd2 7gd7cgd=`gd06gd06gdfgd=i4T46666$6<6>6R6T6r6t666666666667777.707777777$8&8F8P8`8b88888888899::Ѷ hhfFhBehfF6 hfF6hfFhhQ h7ch7c he,h7c h7c6h7ch hh=h= hh06 hZdh06Uh@hghfh=i< If no, list reason for not vaccinating: % Medical contraindication % Religious exemption % Philosophical objection % History of previous disease % Never offered vaccine % Outside recommended age range % Other ________________________ Ethnicity: % Hispanic % Not Hispanic % Other % Unknown Type of infection: % Generalized % Localized % Cephalic % Unknown Date wound occurred: _____/_____/_____ Principal anatomic site: % Head % Trunk % Upper extremity % Lower extremity % Unknown Environment where wound occurred: % Home % Farm/yard % Automobile % Other % Unknown Is infection related it IV drug use? Y N U Is patient pregnant? Y N U Was patient vaccinated after injury, but prior to symptom onset? Y N U Did patient receive TIG after injury, but prior to symptom onset? 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