REPORT Card for Reportable Diseases/Conditions

Use this online form to submit reportable diseases/conditions to the Alabama Department of Public Health. All required fields are marked with a red asterisk (*); it is not possible to submit the report without completing all required fields. Complete the other fields when known. Public Health will follow-up with the reporter for the patient demographics and lab report, if missing.

If you are a laboratorian, reporting on behalf of a laboratory, blood bank, or plasma center, the REPORT Card is not the mechanism you should use to report a patient that has a reportable disease or health condition. Please email mu.elr@adph.state.al.us to learn more about electronic laboratory reporting.

For all other reporters, please complete the requested information below.

Thank you!

Project Name

Date of Report:

M-D-Y

Reportable Disease/Health Condition:

* must provide value

Is this case of public health importance a vaping associated pulmonary injury (VAPI)?

* must provide value

What type of case of public health importance are you trying to report?

* must provide value

You have selected ______ which must be reported to ADPH immediately upon suspicion, by telephone. Please call 1-800-338-8374 to report this case.

PLEASE DO NOT HIT THE SUBMIT BUTTON BELOW FOR THIS 4-HOUR CONDITION.

You have selected to report a case of public health importance (not related to VAPI) to ADPH. Please call 1-800-338-8374 so we may discuss further.

You have selected to report a case of Cholera to ADPH. Unless you have laboratory results stating that this case is positive for toxigenic Vibrio cholerae O1 or O139, please select Vibriosis from the drop-down instead.

You have selected to report a case of Vibriosis to ADPH. If you have laboratory results stating that this case is positive for toxigenic Vibrio cholerae O1 or O139, please select Cholera from the drop-down instead.

You have selected to report a case of Salmonellosis to ADPH.

If you have laboratory results stating that this case is positive for Salmonella Paratyphi A, Salmonella Paratyphi B (tartrate negative), or Salmonella Paratyphi C, please select Paratyphoid Fever from the drop-down instead.

If you have laboratory results stating that this case is positive for Salmonella Typhi, please select Typhoid Fever from the drop-down instead.

You have selected to report a case of Paratyphoid Fever to ADPH. Paratyphoid Fever is caused by the following serotypes: Salmonella Paratyphi A, Salmonella Paratyphi B (tartrate negative), and Salmonella Paratyphi C.

If you have laboratory results stating that this case is positive for Salmonella Typhi, please select Typhoid Fever from the drop-down instead.

If you have laboratory results stating that this case is positive for Salmonella Java, Salmonella Paratyphi B (tartrate positive), or any other Salmonella serotype, please select Salmonellosis from the drop-down instead.

You have selected to report a case of Typhoid Fever to ADPH. Typhoid Fever is caused only by the serotype Salmonella Typhi.

If you have laboratory results stating this case is positive for Salmonella Paratyphi A, Salmonella Paratyphi B (tartrate negative), or Salmonella Paratyphi C, please select Paratyphoid Fever from the drop-down instead. If it is any other serotype, please select Salmonellosis.

Trichinellosis, also called trichinosis, is a disease that people can get by eating raw or undercooked meat from animals infected with the microscopic parasite Trichinella. Trichinellosis IS a reportable condition and SHOULD be entered on this REPORT Card.

It is not to be confused with the STD trichomoniasis, which IS NOT reportable in Alabama and SHOULD NOT be entered on this REPORT Card.

Trichomoniasis is a very common sexually transmitted disease (STD). It is caused by infection with a protozoan parasite called Trichomonas vaginalis. Trichomoniasis IS NOT a reportable condition and SHOULD NOT be entered on this REPORT Card.

It is not to be confused with the gastrointestinal disease trichinellosis (trichinosis), which IS reportable in Alabama and SHOULD be entered on this REPORT Card.

You have selected to report a case of chronic, or past, Hepatitis C infection to ADPH. Click here to enter information about this case into the Hepatitis C Virus Questionnaire.

You have selected to report a case of COVID-19 infection to ADPH. As of April 14, 2024, only cases who are living in congregate living facilities should be reported. A congregate living facility is defined as a facility where persons reside and share common spaces with other residents.

If the case is a resident of a long-term care facility (including skilled nursing facilities*, assisted living facilities, and intermediate care facilities for individuals with an intellectual disability), click here to enter information about this case into the COVID-19 LTC Investigation Form.

If the case is an incarcerated or detained individual at a correctional or detention facility, click here to enter information about this case into the COVID-19 Correctional Facility Investigation Form.

If the case is resident of any other type of congegrate setting (e.g., dormitory, shelter, resident summer camp, mental health facility, etc.), click here to enter information about this case into the COVID-19 Case and Death REPORT Card.

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*Skilled nursing facilities satisfy this reporting requirement by reporting resident cases into the National Healthcare Safety Network (NHSN) as of April 14, 2024.

You have selected to report an acute case of hepatitis C (HCV) to ADPH.

⇒ Reports of acute HCV infection must have documentation of at least one of the following criteria:
✅ Recent seroconversion, i.e., a negative HCV test result in the 6 months preceding the current positive result, and/or
✅ Jaundice, and/or
✅ Peak bilirubin of at least 3.0 mg/dL, and/or
✅ Peak serum alanine aminotransferase (ALT) level of at least 200 IU/L

If the case does not meet at least one of these four criteria, please report as a case of "Hepatitis C, chronic."

Click here to enter information about this case into the Hepatitis C Virus Questionnaire. Please answer all related symptom information within the REPORT Card. If all necessary information is received with this report, our staff will not need to call your office before interviewing the case.

You have selected to report a perinatal case of hepatitis C (HCV) to ADPH.

Perinatal hepatitis C in pediatric patients may range from asymptomatic to fulminant hepatitis.

⇒ Reports of perinatal HCV infection must have documentation of at least one of the following criteria:
✅ HCV RNA positive test results for infants between 2 to 36 months of age, and/or
✅ HCV genotype test results for infants between 2 to 36 months of age or greater, and/or
✅ HCV antigen test results for infants between 2 to 36 months of age or greater

Click here to enter information about this case into the Hepatitis C Virus Questionnaire. Please answer all related symptom information within the REPORT Card. If all necessary information is received with this report, our staff will not need to call your office before interviewing the case.

You have selected to report a case of Acute Flaccid Myelitis (AFM) to ADPH.

Please provide the following information in addition to the information entered on this REPORT Card:

⇒ Complete the Patient Summary Form
⇒ Provide the following clinical information found in the patient's medical record:
✅ Admission and discharge notes
✅ MRI report
✅ MRI images
✅ Neurology consult notes
✅ Infectious disease consult notes
✅ Vaccination record
✅ Diagnostic laboratory results
✅ EMG report (if done and available)

If the documents are not uploaded with this submission, someone from ADPH will be in touch with the reporter shortly to collect the additional information.

You have selected to report an Outbreak to ADPH. An outbreak is when two or more ill individuals become sick with similar symptoms and share a common exposure. Click here to enter information about this potential outbreak.

You have selected to report a case of Novel Influenza A virus Infection (i.e., potential new strain) to ADPH.

Novel influenza A viruses can infect and cause severe respiratory illness in humans. These influenza viruses are DIFFERENT from currently circulating human influenza A virus subtypes and CANNOT be detected by rapid screen/antigen tests.

Influenza A (2009 H1N1) is no longer considered novel.

You have selected to report a case of Shiga-toxin producing Escherichia coli (STEC) to ADPH. STEC are a group of E. coli that can cause serious illness in humans by producing toxins that can severely damage the lining of your intestines and kidneys. It is characterized by diarrhea, which is often bloody. Infection with STEC strains can lead to serious complications like hemolytic uremic syndrome (HUS), which sometimes is fatal.

When you hear reports about outbreaks of E. coli infections, they're usually talking about a type called STEC O157. However, there are other non-O157 serogroups (O26, O111, O103, O121, O45, O145, etc.), that can also produce shiga toxin and cause human illness.

If you have laboratory results stating this case is positive for Enteroinvasive E. coli/Shigella (EIEC), please select Shigellosis from the drop-down instead.

If you have laboratory results stating this case is positive for Enteroaggregative E. coli (EAEC), Enteropathogenic E. coli (EPEC), or Enterotoxigenic E. coli (ETEC), this IS NOT a reportable condition in Alabama and SHOULD NOT be entered on this REPORT Card.

You have selected to report a case of Vaping Associated Pulmonary Injury (VAPI) to ADPH.

Please provide the following information in addition to the information entered on this REPORT Card:

⇒ Provide the following clinical information found in the patient's medical record:
✅ History and Physical
✅ Discharge Summary
✅ Laboratory Reports
✅ Toxicology Reports
✅ Pathology Reports
✅ Radiology Reports
✅ Imaging Reports [e.g., Chest Computed Tomography (CT), Chest Radiograph X-ray, etc.]

If the documents are not uploaded with this submission, someone from ADPH will be in touch with the reporter shortly to collect the additional information.

You have selected to report a case of Multisystem Inflammatory Syndrome in Children (MIS-C), COVID-19 associated to ADPH.

Please provide the following information in addition to the information entered on this REPORT Card:

⇒ Provide the following clinical information found in the patient's medical record:
✅ History and Physical
✅ Discharge Summary
✅ Laboratory Reports
✅ Imaging Reports [e.g., Chest Computed Tomography (CT), Chest Radiograph X-ray, etc.]

If the documents are not uploaded with this submission, someone from ADPH will be in touch with the reporter shortly to collect the additional information.

You have selected to report a case of Monkeypox Virus Infection (Positives Only) to ADPH. If you are not wanting to report a positive result, but rather need to have your patient tested, please submit that request via the Monkeypox Consultation Form.

You have selected to report a result of Lead Testing to ADPH. Click here to enter information about this result into the Lead Testing Report Form.

You have selected to report a Birth defect case to ADPH.

Please ensure that the birth defect being reported is among the birth defects listed in the table below:

Birth Defect	ICD-10 Code	Birth Defect with ICD-10 Code
Anencephaly	Q00.0	Craniorachischisis (Q00.1)
Anotia or congenital absence of ear	Q16.0	Microtia or small ear (Q17.2)
Atrioventricular Septal Defect (Endocardial Cushion Defect)	Q21.2
Cleft hard palate with bilateral cleft lip	Q37.0	Cleft hard palate with unilateral cleft lip (Q37.1) Cleft soft palate with bilateral cleft lip (Q37.2) Cleft soft palate with unilateral cleft lip (Q37.3) Cleft hard and soft palate wiht bilateral cleft lip (Q37.4) Cleft hard and soft palate with unilateral cleft lip (Q37.5) Cleft palate with cleft lip (Q37.6, Q37.7) Unspecified cleft palate with bilateral cleft lip (Q37.8) Unspecified cleft palate with unilateral cleft lip (Q37.9)
Cleft lip bliateral w/o cleft palate	Q36.0	Cleft lip, median (Q36.1) Cleft lip, unilateral (Q36.9)
Cleft hard palate alone w/o cleft lip	Q35.1	Cleft soft palate w/o cleft lip (Q35.3) Cleft hard palate w/ cleft soft palate (Q35.5) Cleft uvula (Q35.7) Cleft palate, unspecified (Q35.9)
Common Truncus (Truncus Arteriosus or TA)	Q20.0
Gastroschisis	Q79.3
Hypoplastic Left Heart Syndrome	Q23.4
Congenital complete absence of unspecified upper limb	Q71.0	Congenital absence of upper arm and forearm w/hand (Q71.1) Congenital absence of both forearm and hand (Q71.2) Congenital absence of hand and finger (Q71.3) Longitudinal reduction defect of radius (Q71.4) Longitudinal reducation defect of ulna (Q71.5) Lobster-claw hand (Q71.6) Other reducation defects of upper limb (Q71.8) Unspecified reduction defect of upper limb (Q71.9)
Congenital complete absence of lower limb	Q72.0	Congenital absence of thigh and lower leg with foot (Q72.1) Congenital absence of both lower leg and foot (Q72.2) Congenital absence of foot and toe(s) (Q72.3) Longitudinal reduction defect of femur (Q72.4) Longitudinal reduction defect of tibia (Q72.5) Longitudinal reduction defect of fibula (Q72.6) Split foot (Q72.7) Other reduction defects of lower limb (Q72.8) Unspecified reduction defect of lower limb (Q72.9)
Cogential absence of unspecified limb(s)	Q73.0	Phocomelia, unspecified limb(s) (Q73.1) Reduction defects of unspecified limb (Q73.2) Other reduction defects of unspecified limb(s) (Q73.8)
Cervical spina bifida with hydrocephalus	Q05.0	Thoracic spina bifida w/ hydrocephalus (Q05.1) Lumbar spina bifida w/ hydrocephalus (Q05.2) Sacral spina bifida w/ hydrocephalus (Q05.3) Unspecified spina bifida w/ hyrdrocephalus (Q05.4) Cervical spina bifida w/o hydrocephalus (Q05.5) Thoracic spina bifida w/o hydrocephalus (Q05.6) Lumbar spina bifida w/o hydrocephalus (Q05.7) Sacral spina bifida w/o hydrocephalus (Q05.8) Unspecified spina bifida (Q05.9) Arnold-Chiari Syndrome w/spina bifida (Q07.01) Arnold-Chiari Syndrome w/spina bifida and hydrocephalus (Q07.3)
Tetralogy of Fallot (TOF)	Q21.3
Total Anamolous Pulmonary Venous Connection (TAPVC)	Q26.2
Transposition of the Great Arteries (TGA) or Discordant ventriculoarterial connection	Q20.3	Corrected transposition, Levotransposition, Ventricular inversion (Q20.5)
Trisomy 21, nonmosaicism	Q90.0	Trisomy 21, mosaicism (Q90.1) Trisomy 21, translocation (Q90.2) Down syndrome, unspecified (Q90.9)

Click here to enter information about this case into the Birth Defects Reporting Form.

Patient's First Name:

* must provide value

Patient's Last Name:

* must provide value

Patient's Phone Number:

* must provide value

Patient's Date of Birth:

* must provide value

M-D-Y

Patient's Age (in years):

View equation

If patient <18 years old, provide parent/proxy's name:

* must provide value

Patient's Date of Death:

* must provide value

M-D-Y

Patient's Gender:

* must provide value

Patient's Race:

* must provide value

If patient's race is other, please specify:

Patient's Ethnicity:

* must provide value

Patient's Marital Status:

Patient's Social Security Number:

Patient's Street Address of Residence:

* must provide value

Patient's City of Residence:

* must provide value

Patient's State of Residence:

* must provide value

Patient's County of Residence:

* must provide value

Patient's Zip Code of Residence:

* must provide value

Patient's Payor Source:

If patient's payor source is other, please specify:

Is the patient symptomatic?

* must provide value

If yes, did the patient have a fever?

* must provide value

If yes, did the patient have a rash?

* must provide value

If yes, did the patient have any lymphadenopathy (swelling of the lymph nodes)?

* must provide value

Date of Onset:

M-D-Y

Date of Diagnosis:

M-D-Y

Date of Exam:

M-D-Y

Date of Laboratory Results:

M-D-Y

Performing Lab Name:

* must provide value

Performing Lab's Accession Number:

* must provide value

Specimen Test Site:

* must provide value

Qualitative Results:

* must provide value

Positive

Negative

Equivocal

Test not done

reset

Syphilis Quantitative Results:

* must provide value

Date of Treatment:

* must provide value

M-D-Y

Treatment:

* must provide value

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Has the patient or patient's proxy been notified by the reporter of this diagnosis or laboratory result?:

* must provide value

Is the patient pregnant?:

* must provide value

You may upload up to three laboratory reports and/or supporting documents for this patient. Demographics must be included in any upload.

How many would you like to upload?:

* must provide value

Document/Result 1:

Upload file

Document/Result 2:

Upload file

Document/Result 3:

Upload file

Reporter Type or On Behalf Of:

* must provide value

If you are a laboratorian, reporting on behalf of a laboratory, blood bank, or plasma center the REPORT Card is not the mechanism you should use to report a patient that has a reportable disease or health condition. Please email mu.elr@adph.state.al.us to learn more.

Reporter's Facility Name:

* must provide value

Investigator Type Code:

Reporter's First Name:

* must provide value

Reporter's Last Name:

* must provide value

Reporter's Phone Number:

* must provide value

Reporter's Street Address:

Reporter's City:

Reporter's State:

Reporter's Zip Code:

Comments:

***Please do not use ampersands (& symbol) or carraige returns (i.e. pressing the enter button to start a new paragraph) when entering into this field.

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Verify Information

Before submitting the REPORT Card, please review the summary below and verify it is accurate. If everything is correct, click the submit button below. Patient name, state, and county are required fields.

If you would like to print this disease/event report prior to submission, click Ctrl plus P on your keyboard.

Date of Submission	______
Disease/Condition	______
Reporter	______ ______, ______, ______
Patient	______ ______ (DOB: ______) / ______, ______

Date/Time Supporting Documents Sent to Division:

M-D-Y H:M

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