New York City health care providers use this four-page form to report notifiable diseases and conditions in city residents, from hepatitis, STIs and tuberculosis to lead and carbon monoxide poisoning, animal bites and drownings. It applies whenever a listed condition is diagnosed, and for some diseases as soon as one is suspected. The NYC Department of Health and Mental Hygiene uses the reports to track and control disease and to detect outbreaks.
The health care provider caring for the patient, or a person reporting on the provider's behalf, completes the whole form: patient, reporter, facility and laboratory details on page 1 and the disease-specific sections on pages 2 to 4. The patient does not fill in any part.
Enter the patient's name and any alias, date of birth, age, country of birth, Social Security and Medicaid numbers, home address with borough, and phone and email. Record the date of report, date of diagnosis and date of illness onset, and a guardian's name if the patient is a child. Answer sex assigned at birth, ethnic or cultural groups and Hispanic origin; gender identity and sexual orientation apply only from age 12. Then cover vital status, pregnancy with due date, suspected health care-associated transmission, newborn details and hospital admission and discharge dates.
List the countries the patient traveled to and the date they returned to the U.S. The malaria entry on page 2 sends you back to this section, so complete it for malaria and any other case where travel matters to the diagnosis. Use the other information field for details that do not fit the structured questions.
Give the name and contact details of the person reporting the disease and their facility, the hospital or facility caring for the patient with its National Provider Identifier (NPI) and Permanent Facility Identifier (PFI) codes, the testing laboratory with its CLIA number, and the provider caring for the patient with an NPI. Answer whether you are reporting as a civil surgeon.
Check the disease being reported. Green entries with an asterisk are immediately notifiable, and dagger entries may be. Many entries carry their own fields: serotype or species, specimen source and test type for invasive bacterial disease, and for hepatitis the jaundice status, ALT and bilirubin values and antibody or antigen results. Hepatitis B in a pregnant or postpartum patient adds maternal results, expected delivery and birth hospital, and the infant's HBIG and first vaccine dose dates and times. Attach diagnostic laboratory results where an entry asks for them.
Complete this block for any disease marked with a dagger. Check whether the patient works in child care, food service, a health care facility, a correctional facility, long-term care, a laboratory or a position with routine animal contact, and whether they attend or live in a school, day care, dormitory, shelter, assisted living, nursing home or correctional facility. Name and locate the workplaces and facilities. If any criterion applies, the case must be phoned to the Provider Access Line immediately.
For an animal bite or other rabies exposure, record the species, breed and colors, whether the animal is owned or stray, the owner's details, the date, body area and activity at the time of the bite, and treatment given, including rabies prophylaxis, HRIG and rabies vaccine. For drownings, give the location and whether the outcome was death, morbidity or no morbidity. Window falls by children are reported separately, as the section notes.
Check the agent (lead, carbon monoxide with its source, arsenic, cadmium, mercury, pesticide or other chemical), the route of exposure, the quantity and the date and time of exposure. Classify the reason and setting as unintentional or intentional, and check symptoms. Record the specimen source, collection and analysis dates, accession number, result with units and purpose of the test, plus vital signs and the treatment provided. For patients 16 and older, add the employer.
Mark whether the patient is under 5 with latent TB infection or a TB suspect or case, and check every site of disease. Enter laboratory results: specimen source and collection date, AFB smear and grade, nucleic acid amplification and mutation analysis, culture, and pathology. Record chest X-ray and CT or MRI findings, the most recent test for TB infection with induration in millimeters, each anti-TB medication with dose, frequency and start date, and airborne isolation dates.
For every STI report, answer how partners were notified or treated, whether the patient is on HIV PrEP, whether doxy PEP was prescribed and the gender of partners in the past year. Then complete the block for the infection: specimen type, test type, collection date and treatment for chlamydia, gonorrhea, chancroid, lymphogranuloma venereum or granuloma inguinale; stage and nontreponemal, treponemal and CSF results for syphilis. Neonatal herpes and congenital syphilis add the delivering parent's details, birth hospital and the infant's signs and treatment.
Use the comments box for anything the structured fields miss. The form directs specific content here: symptoms, risk history and risk factors for hepatitis A, B and C reports marked with a double dagger, and other medical problems or pertinent information for tuberculosis cases.
Download the current version from the source each time; forms change without notice.
Universal Reporting Form
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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The Health Department prefers online reports through PRISM, its Provider Reporting Interface and Secure Messenger, which uses an NYC.ID login. You can also mail the completed form or fax it, calling the Provider Access Line for the right fax number. For immediately notifiable diseases, call first; a written report then follows electronically, by fax or by mail unless the Department says it is unnecessary.
Suspected or confirmed cases of diseases such as anthrax, botulism, measles, invasive meningococcal disease, mpox, rabies or rabies exposure, rubella and viral hemorrhagic fever must be phoned in at once, as must an outbreak in three or more people, an unusual manifestation of any disease, or a newly apparent or emerging disease. Enteric diseases like salmonellosis and shigellosis are immediate only for high-risk groups.
Use the Universal Reporting Form, also referenced as PD-16, for patients who live in New York City; the New York State Department of Health tells health care personnel in the city to use it. For residents of other New York counties, the state's Communicable Disease Reporting Form, DOH-389, goes to the local health department of the county where the patient lives.
No. The form's HIV and AIDS entry points to the New York State Provider Report Form instead. Acute HIV infection should be reported within 24 hours, while HIV infection that is not acute and AIDS are reported within seven days of diagnosis or of receiving the laboratory results. The Health Department supplies the state forms on request.