source: WorldVistAEHR/trunk/r/ICR_IMMUNOLOGY_CASE_REGISTRY-IMR/IMRCDP1.m@ 1639

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