| [613] | 1 | IMRCDP1 ;HCIOFO/NCA - Display CDC Form ;7/16/97 08:53
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| 2 | ;;2.1;IMMUNOLOGY CASE REGISTRY;;Feb 09, 1998
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| 3 | W:'($E(IOST,1,2)'="C-"&IMRCOPI'>1) @IOF
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| 4 | W !,"I. STATE/LOCAL USE ONLY"
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| 5 | W !!,"Patient's Name: ",IMRNAM,?94,"Phone No.: ",IMRPTEL,!," (Last, First, M.I.)",!?114,"Zip",!
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| 6 | W "Address: ",IMRADDR,?41,"City: ",IMRADDR2,?68,"County: ",$S(IMRCNTY'="":IMRCNTY,1:"__________________"),?96,"State: ",$S(IMRSTATE'="":IMRSTATE,1:"________")
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| 7 | W ?114,"Code: ",IMRZIP,!!!
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| 8 | W !,"VII. STATE/LOCAL USE ONLY",!!?94,"Medical"
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| 9 | W !,"Physician's Name: ",IMRPHYS,?65,"Phone No.: ",IMRPHYST,?94,"Record No. ",IMRSSN,!," (Last, First, M.I.)",!?57,"Person"
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| 10 | S X=""
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| 11 | I IMRPT'="" S X=$$FIELD^IMRCDCPX(158,IMRPT,15.6,"E")
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| 12 | W !,"Hospital/Facility: ",X,?57,"Completing Form: ",IMRUSR,?99,"Phone No.: ",IMRUSRT,!!!
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| 13 | W !,"This report is authorized by law (Sections 304 and 306 of the Public Health Service Act, 42 USC 242b and 242k). Response in this"
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| 14 | W !,"base is voluntary for federal government purposes, but may be mandatory under state and local statutes. Your cooperation is"
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| 15 | W !,"necessary for the understanding and control of HIV/AIDS. Information in the surveillance system that would permit identification"
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| 16 | W !,"of any individual on whom a record is maintained, is collected with a guarantee that it will be held in confidence, will be used"
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| 17 | W !,"only for the purposes stated in the assurance on file at the local health department, and will not otherwise be disclosed or"
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| 18 | W !,"released without the consent of the individual in accordance with Section 308(d) of the Public Health Service Act (42 USC 242m).",!!
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| 19 | W !,"Public burden for this collection of information is estimated to average 10 minutes per response. Send comments regarding this"
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| 20 | W !,"burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to PHS"
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| 21 | W !,"Reports Clearance Officer: ATTN: PRA; Hubert H. Humphrey Bldg. Rm 721-B; 200 Independence Ave., SW; Washington, DC 20201, and to"
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| 22 | W !,"the Office of Management and Budget; Paperwork Reduction Project (0920-0009); Washington, DC 20503. -DO NOT MAIL CASE REPORT FORMS"
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| 23 | W !,"TO THESE ADDRESSES --",!!!
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| 24 | W !,"RETURN TO STATE/LOCAL HEALTH DEPARTMENT - PATIENT IDENTIFIER INFORMATION IS NOT TRANSMITTED TO CDC! -"
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| 25 | W @IOF
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| 26 | W !,"U.S. DEPARTMENT OF HEALTH ADULT HIV/AIDS CONFIDENTIAL CASE REPORT CDC"
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| 27 | W !,"& HUMAN SERVICES (Patients >=13 years of age at time of diagnosis) CENTERS FOR DISEASE CONTROL"
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| 28 | W !,"Public Health Service AND PREVENTION"
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| 29 | W !?47,"II. HEALTH DEPARTMENT USE ONLY"
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| 30 | W !,"DATE FORM COMPLETED" S LN="",$P(LN,"=",108)="" W !,?24,LN
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| 31 | W !?4,"MO. DAY YR. | SOUNDEX REPORT STATUS REPORTING HEALTH DEPARTMENT STATE |"
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| 32 | W !?4,IMRCDC,?23,"| CODE STATE: _______________ PATIENT NO.: __________ |"
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| 33 | W !,"===================== |",?43,"| | NEW REPORT CITY/ CITY/COUNTY |"
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| 34 | W !,"| REPORT SOURCE: ___ | | ____ | | UPDATE COUNTY:_______________ PATIENT NO.: __________ |"
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| 35 | W !,"===================== ",LN
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| 36 | W !,"------------------------------------------------- III. DEMOGRAPHIC INFORMATION -------------------------------------------------"
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| 37 | W !,"DIAGNOSTIC STATUS AGE AT DIAGNOSIS: | DATE OF BIRTH | CURRENT STATUS | DATE OF DEATH | STATE/TERRITORY OF DEATH"
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| 38 | D HDR^IMRCDCPR
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| 39 | Q
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