Maine Department of Health and Human Services Maine Center for Disease Control and Prevention Division of Infectious Disease Notifiable Disease Reporting Form Notifiable Condition or Disease: (Attach lab results if available) Reporting Information Person Reporting: Title: Agency/Institution: Phone: - - Phone: - - Patient Information Name: (Last, First MI) Address: State: Town: Zip: Date of Birth: / Hispanic or Latino: Yes Race: / Gender: No Male Female Unknown White Black or African-American Asian Unknown Native Hawaiian/Pacific Islander American Indian/Alaskan Native Two or More Races Other – Specify Clinical Information Specimen Source: Blood Cervix Joint Fluid Nasopharyngeal Sputum Stool Urethra Urine Other – Specify Specimen Collection Date: / Lab that Performed Test: Is patient hospitalized: Spinal Fluid / Lab Test Name/Type: YesWhere? No Provider Name: Phone: Practice Name: Town: - - Fax form to Division of Infectious Disease at (800) 293-7534 or (207) 287-8186 September 8, 2015