ALABAMA DEPARTMENT of PUBLIC HEALTH
 
VPD REPORT Card

Rules for Every Provider and Organization to Report on Time
Alabama Department of Public Health, adph.org

Laboratories -- The VPD REPORT Card is no longer an acceptable way for laboratories to report notifiable diseases. Please call the Epidemiology Division at 1-800-338-8374 for further reporting instructions.

* Patient's First Name:

* Patient's Last Name

* Patient's Phone
Area code and Number

* Patient's Date of Birth:

* Patient's Gender


* Patient's Race


Use Shift or Ctrl keys to select multiple values.

* Patient's Ethnicity

Hispanic Not hispanic

* Patient's Address:

* Patient's City

* Patient's State


Other:

* Patient's Zip

* Patient's County of Residence


Patient's Payor Source


Other:

* Reportable Disease/Health Condition:
For Immediate, Urgent or Standard Notification Diseases, select from the drop-box. For Immediate, Extremely Urgent Diseases, please call 1-800-338-8374 within 4 hour of diagnosis.


You must submit at least 1 of 3 date fields listed below:

Date of Onset:

Date of Diagnosis:

Date of Lab Results:

If you have a laboratory report resulting the disease you have selected above please fax it to 334-206-3734. Patient demographics (date of birth, address, phone number) must be included with the report.

* Reporter Type or On Behalf Of


* Reporter Facility Name

* Reporter's First Name:

* Reporter's Last Name

* Reporter's Area Code and Phone:

Reporter's Address:

Reporter's City

Reporter's Zip

Comments:

If you would like an email confirmation of this report, provide your email address.



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Alabama Department of Public Health