CDS-1, Communicable Disease Report
|New Jersey Department of Health |COMMUNICABLE DISEASE REPORT |
|(For Submission to Local Health Department) |(NOTE: Shaded areas are for Local Health Department Use Only.) |
|Name of Disease (Specify Organism) |Setting of Infection |State E No. |CDRS ID No. |
| |Sporadic Case |E- | |
| |Household Cluster | | |
| |Institutional Cluster | | |
| |Outbreak | | |
|Name of Patient (Last) (First) (MI) |Date of Birth |Telephone Number |
| | |( ) |
| | | |/ | |/ | | | |
| | Month Day Year | |
|Onset Date of Illness |Age |If ................
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