► Download a paper version of the URF

Page One

Patient Information: Complete all requested information. In addition to the other demographic information, please complete the 'Date of Report' (upper right hand corner), 'Zip Code,' 'Borough,' 'Race,' Ethnicity,' the section labeled 'Risk Groups for Disease Exposure,' 'Date of Diagnosis,' and 'Date of Illness Onset'

Reporter Information: Complete all requested information

Disease (Code) with Special Instructions (continues on page 2)

• Clearly mark the box to the left of the disease you are reporting
• Specify organisms, sites, specific test results, species, and serogroups where indicated
• Complete any additional requested information
• Note: Disease names printed in green with one asterisk denote diseases that must be reported immediately. Call the Provider Access Line at 1-866-NYC-DOH1 during business hours; after 5PM call the Poison Control Center at 1-800-222-1222.
• Note: For enteric pathogens (marked with two asterisks), please complete the section labeled 'Risk Groups for Disease Exposure' located in the 'Patient Information' section
• Note: For sexually transmitted diseases (marked with a green ���), indicate the gender of sexual partners in the past year (footnoted section, page 2)
• Information on how to report animal bites, HIV/AIDS, and window falls is available within the 'Disease (Code)' section

Page Two

Patient Name & Medical Record Number: Complete the 'Patient Last Name,' 'First Name,' and 'Medical Record Number' at the top of Page 2

Disease (Code) with Special Instructions (continued from page one): Follow instructions as listed for Page 1

Poisoning: Clearly mark the circle to the left of the appropriate poison and specimen types as well as the 'Purpose of Test'. Complete the additional requested information

Sexually Transmitted Diseases

• Clearly mark the box to the left of the disease you are reporting
• Complete any additional requested information including sites, test types, treatments, test dates, and stage of disease (for syphilis)
• Indicate the gender of sexual partners in the past year (footnoted section).

Tuberculosis

• Complete all requested information
• Complete the section 'Risk Groups for Disease Exposure' on page one in the 'Patient Information' section

Where to send completed URFs

Mail all completed reports to:

NYC DOHMH, Division of Disease Control
42-09 28th Street 5th Floor, CN-22
Queens, NY 11101-4132

To order more URFs

Call the Provider Access Line 1-866-NYC-DOH1 (allow 2-3 weeks for delivery). The URF can also be downloaded and printed.

Questions? Call the Provider Access Line at 1-866-NYC-DOH1

• Communicable diseases as listed in the section entitled 'Disease (code) with special instructions' (Pages 1 and 2 of the URF)
• Poisoning cases as listed in the section 'Poisoning' (Page 2 of the URF)
• Sexually transmitted diseases as listed in the section 'Sexually Transmitted Diseases' (Page 2 of the URF)
• Tuberculosis in section 'Tuberculosis' (Page 2 of the URF)

* Note: this form does not replace any other DOHMH forms (such as the IMM5 form for reporting hepatitis B in pregnant women or the CDC Malaria Case Surveillance Report)

Call DOHMH if there is an outbreak or suspected outbreak of any disease or condition, of known or unknown etiology, which may be a danger to public health, occurring in three or more persons or any unusual manifestation of a disease in an individual.

Call the Provider Access Line 1-866-NYC-DOH1 during business hours; after 5PM call the Poison Control Center at 1-800-222-1222.

Did you know that you can now complete and submit URFs online?