New Hampshire clinicians use this one-page form (2017), which DHHS calls the General Disease Reporting Form, for infectious diseases on the state's reportable list that have no disease-specific form. RSA 141-C and He-P 301 require reports of suspect and confirmed cases; diseases marked with an asterisk must be reported within 24 hours of diagnosis, and all others within 72 hours.
The reporting clinician or office staff completes the patient, symptom, treatment and reporting sections, naming the healthcare provider and facility. There is no patient section.
Download the current version from the source each time; forms change without notice.
New Hampshire Confidential Communicable Disease Report Form
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Those marked with an asterisk on the reportable list printed on the form, including anthrax, botulism, cholera, diphtheria, invasive Haemophilus influenzae and Neisseria meningitidis disease, hepatitis A, mumps, pertussis, rabies and rubella. Report them within 24 hours of diagnosis, and all other listed diseases within 72 hours.
No. DHHS says submitting a specimen with a completed Clinical Laboratory Test Requisition to the NH Public Health Laboratories does not meet a provider's or laboratory's obligation to report to the Bureau of Infectious Disease Control. The case still needs a report by form, phone or electronic account.