Laboratory-confirmed COVID-19 Case and Death REPORT Card

Use this online form to submit laboratory-confirmed (or pre-approved epidemiologically-linked) cases or deaths of Novel Coronavirus (COVID-19) 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.

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

Thank you!

M-D-Y

A laboratory-confirmed COVID-19 case

A laboratory-confirmed COVID-19 case who has died

An individual with compatible COVID-19 symptoms AND exposure to a known COVID-19 case (no laboratory testing performed)

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Yes

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ADPH Bureau of Clinical Laboratories

Commercial Laboratory

Clinical Laboratory

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M-D-Y

View equation

Yes

Unknown

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M-D-Y

You have selected to report a Novel Coronavirus death 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:
✅ Facesheet (including patient demographics)
✅ History and physical
✅ Positive COVID-19 laboratory report
✅ Discharge summary (to include date and time of death)

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.

Yes

Unknown

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During this illness, did the patient experience any of the following symptoms?

NOTE: If the symptoms are not provided with this submission, someone from ADPH will be in touch with the reporter shortly to collect the additional information.

Yes

Unknown

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M-D-Y

Yes

Unknown

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Yes

Unknown

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Yes

Unknown

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Yes

Unknown

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M-D-Y

Detected

Not Detected

Indeterminate

Inconclusive

Invalid

Unsatisfactory

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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.

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: ______) / ______, ______

M-D-Y H:M

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