Hepatitis C Surveillance
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Report Form

Please use this page to report new cases of Hepatitis C. All information will be kept confidential. Your cooperation in helping us better understand the epidemiology of Hepatitis C is greatly appreciated.

Patient Information:

Last Name:
First Name:
Telephone #:
Email:
Mailing Address:
Date of Birth:
Gender: Male Female
Date of Diagnosis:

Laboratory Tests:
Serology: positive negative
PCR: positive negative
Liver Function Tests: positive elevated normal
Risk Factors Reported
(check all that apply):
IV drug user
Transplant Recipient
more than 4 sexual partners
Incarcerated/Institutionalized
Other (please specify):

Reporting Physician's Information:

Last Name:
First Name:
Telephone #:
Email:
Mailing Address:

Hepatitis C Surveillance Program
School of Public Health
Epidemiology 414
Email: javan@hotmail.com

Disclaimer : This website was designed as part of course on web design. Please do not use this web site as a reporting tool.