New Jersey providers who cannot enter a syphilis case directly in CDRSS, the state's preferred route, report it on this form. It records the patient, pregnancy and estimated delivery date, the stage (primary through late latent, unknown duration or congenital), neuro, ocular or otic involvement, symptoms, and prior syphilis testing and treatment, and must be faxed with the lab report.
The examining provider or clinic staff completes it, and the reporting clinic block names both the person completing the form and the examining provider. Questions printed in red are required.
Download the current version from the source each time; forms change without notice.
Syphilis Case Report Form
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Yes. The STD-11a states the lab report must be faxed with the case report form, and the lab results section repeats it. Required questions are printed in red, and NJDOH asks that all required fields be complete before you submit the form.
Physicians, advanced practice nurses and physician assistants, plus those who oversee hospitals, health care facilities, correctional facilities, schools, camps, child care centers, preschools and colleges. Laboratories follow their own rules under N.J.A.C. 8:57-1.7. Direct entry in CDRSS is preferred over the paper form.