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STD Case Report form - Jefferson County Public Health - jeffersoncountypublichealth

STD Case Report form - Jefferson County Public Health - jeffersoncountypublichealth 2026

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The document is a confidential sexually transmitted disease (STD) case report form used by Jefferson County Public Health. It includes sections for patient information, diagnosis of STDs such as gonorrhea, chlamydia, syphilis, and herpes simplex, treatment regimens, and partner management plans. The form emphasizes the importance of reporting STDs within three workdays and provides guidelines for ensuring partner treatment and follow-up. It also outlines recommended antimicrobial regimens for various STDs and includes a fax prescription section for expedited partner therapy.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the 'Patient Information' section. Enter the patient's last name, first name, middle initial, address, telephone number, city, state, zip code, date of birth, and ethnicity. Ensure all fields are completed accurately.
In the 'Reason for Exam' section, check the appropriate box that describes why the patient is being examined: symptomatic, routine exam with no symptoms, or exposed to infection.
Proceed to the 'Diagnosis' section. Select the disease diagnosed (e.g., Gonorrhea or Chlamydia) and indicate if it was lab confirmed. Fill in any relevant details regarding treatment prescribed and dates.
Complete the 'Partner Management Plan' by selecting a method for ensuring partner treatment. This may include indicating how many partners will be treated and whether health department assistance is needed.
Finally, fill out the 'Reporting Clinic Information' section with details about the diagnosing clinician and facility. Ensure all contact information is accurate for follow-up purposes.

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Versions	Form popularity	Fillable & printable
2021	4.8 Satisfied (206 Votes)
2019	4.4 Satisfied (110 Votes)
2011	4 Satisfied (47 Votes)

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What STDs have to be reported?

The answer may surprise you. As a general rule, no, you do not have an obligation to tell your partner if you have a sexually transmitted disease. There arent any federal or state laws making it illegal for you to not tell a partner about an STD you may have.

What STDs are you required to disclose?

Non-reportable STIs are: Genital . Human Papillomavirus (HPV) Pediculosis (Pubic Lice) Trichomoniasis.

Which sexually transmitted infection must be reported to the local health department?

The Disease Control and Epidemiology unit monitors the rates of reportable sexually transmitted diseases (STDs). These include gonorrhea, chlamydia and syphilis. In addition, Hepatitis B, AIDS, and other reportable infections that are sexually transmissible are counted.

How do I report an STI in Kentucky?

Qualified Health Department staff provide investigations of the cases and report the communicable diseases to the state office which reports to Centers for Disease Control and Prevention. To report diseases, using the following contacts: Sexually transmitted diseases: 859-363-2075. : 859-363-2072.

What STDs need to be reported to the CDC?

In Ohio, healthcare providers and facilities are required per Ohio Administrative Code 3701-3-02 to report the occurrence of cases or suspected cases of Chancroid, Chlamydia, Gonorrhea and Syphilis infection under their care and treatment to the public health authority.

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