Modify Form Now

Fill Out Your Ph1600 Tennessee Form

The PH1600 Tennessee form is a crucial document used to report communicable diseases and events that pose a risk to public health. Hospitals, physicians, and laboratories must submit this form to their local health department when they know or suspect a case. For guidance on filling out this form, click the button below.

Modify Form Now

Table of Contents

The PH1600 form is an essential tool for reporting communicable diseases and events in Tennessee. This form is utilized by hospitals, physicians, laboratories, and other individuals who suspect or know of a case that poses a risk to public health. It is important to understand that certain diseases and events must be reported immediately, while others require a written report within a week. The form captures critical patient information, including demographics, clinical status, and laboratory test results. It also provides a structured way to report specific diseases, categorized by urgency. For example, Category 1A diseases necessitate immediate telephonic notification, while Category 2 diseases require a written report within one week. The form ensures that local health departments receive timely information, enabling them to respond effectively to potential outbreaks. For those needing further clarification, additional resources are available, including a Reportable Diseases and Events Matrix, which outlines the specific diseases that must be reported. By adhering to these reporting requirements, healthcare providers play a crucial role in safeguarding the health of the community.

Ph1600 Tennessee Sample

Tennessee Department of Health Reportable Diseases and Events

The diseases and events listed on the back of this report are declared to be communicable and/or dangerous to the public and are to be reported to the local health department by all hospitals, physicians, laboratories, and other persons knowing of or suspecting a case in accordance with the provision of the statutes and regulations governing the control of communicable diseases in Tennessee (T.C.A. §68 Rule 1200-14-01-.02). For more specific details, download the Reportable Diseases and Events Matrix (http://health.state.tn.us/ceds/notifiable.htm). If further guid- ance is needed, contact Communicable and Environmental Disease Services at (615) 741-7247 or (800) 404-3006.

Disease/Event Code:
	Patient Name:
	Patient Name:

	Date of Birth:		Race: □ American Indian / Alaskan
	____/____/________				□ Asian
Demographics	Gender:	□ Male			□ Black / African American
Demographics		□ Female			□ Hawaiian / Pacific Islander
					□ White
	Ethnicity: □ Hispanic				□ White
	Ethnicity: □ Hispanic				□ Other (_________________)
		□ Not Hispanic			□ Other (_________________)
		□ Not Hispanic
	Street Address:

	City:					State:

	County:					Zip Code:

	Phone: (	)
	Onset Date: ____/____/________
Information
Information	Died?:	□ Yes			Pregnant?:	□ Yes
	Hospitalized?: □ Yes				Admission Date: ____/____/________
		□ No
		□ Unknown			Discharge Date: ____/____/________
Clinical		□ No				□ No
Clinical		□ Unknown				□ Unknown
		□ Unknown				□ Unknown
	STD Treatment Date:				STD Treatment:
	____/____/________

Provider	Physician Name:

	Facility/Hospital Name:
	Facility/Hospital Name:

	Phone: (	)

Laboratory	Test:

	Specimen Collection Date:			Result:
	Specimen Collection Date:			Result:
	____/____/________

	Specimen Source:

Disease/Event Code:
	Patient Name:
	Patient Name:

	Date of Birth:		Race: □ American Indian / Alaskan
	____/____/________				□ Asian
Demographics	Gender:	□ Male			□ Black / African American
Demographics		□ Female			□ Hawaiian / Pacific Islander
					□ White
	Ethnicity: □ Hispanic				□ White
	Ethnicity: □ Hispanic				□ Other (_________________)
		□ Not Hispanic			□ Other (_________________)
		□ Not Hispanic
	Street Address:

	City:					State:

	County:					Zip Code:

	Phone: (	)
	Onset Date: ____/____/________
Information
Information	Died?:	□ Yes			Pregnant?:	□ Yes
	Hospitalized?: □ Yes				Admission Date: ____/____/________
		□ No
		□ Unknown			Discharge Date: ____/____/________
Clinical		□ No				□ No
Clinical		□ Unknown				□ Unknown
		□ Unknown				□ Unknown
	STD Treatment Date:				STD Treatment:
	____/____/________

Provider	Physician Name:

	Facility/Hospital Name:
	Facility/Hospital Name:

	Phone: (	)

Laboratory	Test:

	Specimen Collection Date:			Result:
	Specimen Collection Date:			Result:
	____/____/________

	Specimen Source:

Date of Report: ____/____/________ Person Reporting/Title: ___________________________________________ Phone: ( ______ ) ________________

PH-1600 (Rev. 01/2011)

RDA-2094

Category 1A: Requires immediate telephonic notification (24 hours a day, 7 days a week), followed by a written report using the PH-1600 within 1 week.

[002]	Anthrax (Bacillus anthracis)B	[095]	Meningococcal Disease (Neisseria meningitidis)
[005]	Botulism-Foodborne (Clostridium botulinum)B	[516]	Novel Influenza A
[004]	Botulism-Wound (Clostridium botulinum)	[032]	Pertussis (Whooping Cough)
[505]	Disease Outbreaks (e.g., foodborne, waterborne, healthcare, etc.)	[037]	Rabies: Human
[108]	Encephalitis, Arboviral: Venezuelan EquineB	[112]	Ricin PoisoningB
[023]	Hantavirus Disease	[132]	Severe Acute Respiratory Syndrome (SARS)
[096]	Measles-Imported	[107]	SmallpoxB
[026]	Measles-Indigenous	[110]	Staphylococcal Enterotoxin B (SEB) Pulmonary PoisoningB

Category 1B: Requires immediate telephonic notification (next business day), followed by a written report using the PH-1600 within 1 week.

[006]Brucellosis (Brucella species)B

[010]Congenital Rubella Syndrome

[011]Diphtheria (Corynebacterium diphtheriae)

[121]Encephalitis, Arboviral: California/LaCrosse Serogroup

[123]Encephalitis, Arboviral: Eastern Equine

[122]Encephalitis, Arboviral: St. Louis

[124]Encephalitis, Arboviral: Western Equine

[506]Enterobacteriaceae, Carbapenem-resistant

[053]Group A Streptococcal Invasive Disease (Streptococcus pyogenes)

[047]Group B Streptococcal Invasive Disease (Streptococcus

agalactiae)

[054]Haemophilus influenzae Invasive Disease

[016]Hepatitis, Viral-Type A acute

[513]Influenza-associated deaths, age <18 years

[520]Influenza-associated deaths, pregnancy-associated

Category 2: Requires written report using form PH-1600 within 1 week.

[501]Babesiosis

[003]Botulism-Infant (Clostridium botulinum)

[007]Campylobacteriosis (including EIA or PCR positive stools)

[503]Chagas Disease

[069]Chancroid

[055]Chlamydia trachomatis-Genital

[057]Chlamydia trachomatis-Other

[056]Chlamydia trachomatis-PID

[009]Cholera (Vibrio cholerae)

[001]Cryptosporidiosis (Cryptosporidium species)

[106]Cyclosporiasis (Cyclospora species)

[504]Dengue Fever

[116]Ehrlichiosis-HGE (Anaplasma phagocytophilum)

[051]Ehrlichiosis-HME (Ehrlichia chaffeensis)

[117]Ehrlichiosis/Anaplasmosis-Other

[060]Gonorrhea-Genital (Neisseria gonorrhoeae)

[064]Gonorrhea-Opthalmic (Neisseria gonorrhoeae)

[061]Gonorrhea-Oral (Neisseria gonorrhoeae)

[063]Gonorrhea-PID (Neisseria gonorrhoeae)

[062]Gonorrhea-Rectal (Neisseria gonorrhoeae)

[133]Guillain-Barré syndrome

[058]Hemolytic Uremic Syndrome (HUS)

[480]Hepatitis, Viral-HbsAg positive infant

[048]Hepatitis, Viral-HbsAg positive pregnant female

[017]Hepatitis, Viral-Type B acute

[018]Hepatitis, Viral-Type C acute

[021]Legionellosis (Legionella species)

[022]Leprosy [Hansen Disease] (Mycobacterium leprae)

[094]Listeriosis (Listeria species)

[024]Lyme Disease (Borrelia burgdorferi)

[025]Malaria (Plasmodium species)

[515]Melioidosis (Burkholderia pseudomallei)

[102]Meningitis-Other Bacterial

[031]Mumps

[033]Plague (Yersinia pestis)B

[035]Poliomyelitis-Nonparalytic

[034]Poliomyelitis-Paralytic

[119]Prion disease-variant Creutzfeldt Jakob Disease

[109]Q Fever (Coxiella burnetii)B

[040]Rubella

[041]Salmonellosis: Typhoid Fever (Salmonella Typhi)

[131]Staphylococcus aureus: Vancomycin non-sensitive – all forms

[075]Syphilis (Treponema pallidum): Congenital

[519]Tuberculosis, confirmed and suspect cases of active disease

(Mycobacterium tuberculosis complex)

[113]Tularemia (Francisella tularensis)B

[118]Prion disease-Creutzfeldt Jakob Disease

[036]Psittacosis (Chlamydia psittaci)

[105]Rabies: Animal

[042]Salmonellosis: Other than S. Typhi (Salmonella species)

[517]Shiga-toxin producing Escherichia coli (including Shiga-like

toxin positive stools, E. coli O157 and E. coli non-O157)

[043]Shigellosis (Shigella species)

[039]Spotted Fever Rickettsiosis (Rickettsia species including Rocky

Mounted Spotted Fever)

[130]Staphylococcus aureus: Methicillin resistant Invasive Disease

[518]Streptococcus pneumoniae Invasive Disease (IPD)

[074]Syphilis (Treponema pallidum): Cardiovascular

[072]Syphilis (Treponema pallidum): Early Latent

[073]Syphilis (Treponema pallidum): Late Latent

[077]Syphilis (Treponema pallidum): Late Other

[076]Syphilis (Treponema pallidum): Neurological

[070]Syphilis (Treponema pallidum): Primary

[071]Syphilis (Treponema pallidum): Secondary

[078]Syphilis (Treponema pallidum): Unknown Latent

[044]Tetanus (Clostridium tetani)

[045]Toxic Shock Syndrome: Staphylococcal

[097]Toxic Shock Syndrome: Streptococcal

[046]Trichinosis

[101]Vancomycin resistant enterococci (VRE) Invasive Disease

[114]Varicella deaths

[104]Vibriosis (Vibrio species)

[125]West Nile virus Infections-Encephalitis

[126]West Nile virus Infections-Fever

[098]Yellow Fever

[103]Yersiniosis (Yersinia species)

Category 3: Requires special confidential reporting to designated health department personnel within 1 week.

[500] Acquired Immunodeficiency Syndrome (AIDS)

[512] Human Immunodeficiency Virus (HIV)

Category 4: Laboratories and physicians are required to report all blood lead test results monthly and no later than 15 days following the end of the month.

[514]Lead Levels (blood)

Category 5: Events will be reported monthly (no later than 30 days following the end of the month) via the National Healthcare Safety Network (NHSN

see http://health.state.tn.us/ceds/hai/index.htm for more details); CLOSTRIDIUM DIFFICILE infections (Davidson County residents only) will also be reported monthly to the Emerging Infections Program (EIP).

[508]	Healthcare Associated Infections, Central Line Associated	[510]	Healthcare Associated Infections, Methicillin resistant
	Bloodstream Infections		Staphylococcus aureus positive blood cultures
[509]	Healthcare Associated Infections, Clostridium difficile	[511]	Healthcare Associated Infections, Surgical Site Infections

The following pathogens do not need to be reported using form PH-1600, but a reference culture is required to be sent to the State Public Health Laboratory.

[502] Burkholderia malleiB	[507] Francisella speciesB

BPossible Bioterrorism Indicators	See matrix for additional details.	Effective 01/01/2011

⇓ Ph1600 Tennessee PDF Form

Document Details

Fact Name	Details
Purpose	The PH1600 form is used to report communicable diseases and events to the local health department in Tennessee.
Governing Laws	This form is governed by Tennessee Code Annotated (T.C.A.) §68 and Rule 1200-14-01-.02, which outline the control of communicable diseases.
Reporting Requirements	All hospitals, physicians, laboratories, and individuals aware of or suspecting a case must report using this form, adhering to specified timelines.
Categories of Diseases	The form categorizes reportable diseases into five categories, each with distinct reporting timelines and requirements.

Please rate Fill Out Your Ph1600 Tennessee Form Form

4.67

(Stellar)

21 Votes

More PDF Forms

Tennessee Llc Annual Fees - Crucial for updating the state's records regarding an LLC in Tennessee, encompassing changes from contact information to structural alterations.

The FedEx Bill of Lading form is an essential shipping document that provides details about the transport of goods. This form serves as a contract between the shipper and the carrier, outlining responsibilities and requirements for the shipment. For those looking to create or utilize this document efficiently, resources such as PDF Templates Online can be incredibly helpful in streamlining the shipping process and avoiding complications.

Franchise and Excise Tax - Calendar for Tennessee tax exemption application and renewal deadlines.