New Hampshire providers use this one-page fillable form to report chlamydia, gonorrhea and syphilis to the Bureau of Infectious Disease Control under RSA 141-C and He-P 300. Beyond test results, it records treatment given, pregnancy status, symptoms, sites tested and expedited partner therapy. The form asks for prompt reporting of suspect and confirmed cases within 72 hours of diagnosis.
The health care provider or person reporting completes the whole form, including the provider, facility and reporter block at the bottom. There is no patient section.
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New Hampshire Confidential STI Reporting Form
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The form requests prompt reporting of suspect and confirmed cases within 72 hours of diagnosis. RSA 141-C and He-P 300 require physicians, laboratories and health care providers to report chlamydia, gonorrhea, syphilis and HIV, and all reports are handled under strict confidentiality standards.
Yes. The form has treatment dates and regimen checkboxes for chlamydia, gonorrhea and syphilis, with space for other treatment, and links to current STI treatment guidelines. It also asks about drug allergies, pregnancy status, symptoms and their onset date, and the sites tested.