New Jersey providers who cannot enter a chlamydia case directly in CDRSS report it on this one-page fillable form (JUL 22). It records the patient, pregnancy, reason for exam, HIV testing and PrEP, infection sites, treatment, partner medication and any positive gonorrhea labs. It also has a block for lymphogranuloma venereum (LGV) with verified and likely case definitions.
The examining provider or clinic staff completes it, naming both the person completing the form and the examining provider in the reporting clinic block.
Download the current version from the source each time; forms change without notice.
Chlamydia Case Report Form
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On the STD-11c, check the LGV box and attach the lab report. The form defines a verified case as detection of LGV-specific antigen or nucleic acid, including asymptomatic cases, and a likely case as C. trachomatis detection with consistent symptoms or signs and no negative LGV-specific test.
NJDOH lists the disease, the patient's name, age, date of birth, address, phone, gender, race and ethnicity, symptoms, treatment with medication, dosage and dates, and the reporting official's name, address, direct phone and institution. The STD-11c captures these along with the examining provider's details.