COMMUNICABLE DISEASES ALERT, LCS-4
New Jersey Department of Health
PO Box 358
Trenton, NJ 08625-0358
COMMUNICABLE DISEASES ALERT
|SECTION I - INSTRUCTIONS |
| |
|The following is a list of contagious, infection or communicable diseases developed in accordance with the provisions of P.L. 1988, C. 125 (N.J.S.A. 26:6-8.2). |
|Funeral directors must be notified in writing if the deceased individual had any of these diseases at the time of death. |
| |
|Such notification shall be accomplished by placing this form with the remains and forwarding a copy of same to the funeral director. The body shall not be |
|released until this form is completed and placed with the remains. |
| |
|-Human Immunodeficiency Virus -Smallpox |
|Infections including AIDS -Syphilis-Primary and |
|(Acquired Immune Deficiency Secondary (Untreated) |
|Syndrome) -Toxoplasmosis Disseminated (Untreated) |
|-Anthrax -Tuberculosis (Untreated) |
|-Creutzfeldt-Jakob Disease -Tularemia |
|-Viral Hepatitis B -Typhoid Fever (Untreated) |
|-Malaria (Untreated) -Viral Hemorrhagic Fevers |
|-Meningococcal Disease (Untreated) (Contact State Health |
|-Plague (Untreated) Department Immediately) |
|-Q Fever (Untreated) -Yellow Fever (First 5 Days of Infection) |
|-Rabies |
| |
|Complete Section II if the deceased had one or more of the above diseases. |
|SECTION II |
|Name of Deceased |Date of Death |
| | |
|Name of Health Care Facility |Name of Funeral Director |
| | |
|I am the attending physician, registered professional nurse or state or county medical examiner who made the determination and pronouncement of death and I have|
|determined or I have knowledge that the above-named individual suffered from one of the communicable diseases listed in Section I above at the time of his/her |
|death. |
| |
|All persons performing or assisting in post-mortem procedures should wear gloves, masks, protective eyewear, gowns and waterproof aprons. Instruments and |
|surfaces contaminated during post-mortem procedures should be decontaminated with an appropriate chemical germicide. |
|Name of Pronouncer (Print) |Signature |Date |
| | | |
Distribution: Original - Funeral Director
Copy - Health Care Facility
Copy - Attach to Remains
LCS-4
JUL 12
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