Printable Maryland Confidential Morbidity Report Template

The Maryland Confidential Morbidity Report (DHMH 1140) is a crucial document designed for use by physicians and other health care providers to report certain diseases and conditions. This form helps local health departments track and manage public health issues effectively. For health care providers, filling out this form accurately is essential for the well-being of the community; click the button below to start the process.

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The Maryland Confidential Morbidity Report form, designated as DHMH 1140, serves a crucial role in the public health landscape by enabling healthcare providers to report specific diseases and conditions to local health departments. This form is primarily utilized by physicians and other healthcare professionals, excluding laboratories, which have their own designated reporting forms. Essential details required on the form include patient demographics such as name, date of birth, sex, ethnicity, and contact information. Furthermore, it captures vital occupational information, particularly regarding interactions with vulnerable populations. The form also necessitates the documentation of the disease or condition, including onset dates, hospital admission details, and any relevant laboratory test results. The reporting process is designed to maintain patient confidentiality while facilitating timely public health responses. Additional sections address conditions related to sexually transmitted infections, tuberculosis, and HIV/AIDS, allowing for comprehensive data collection. Notably, the form emphasizes the importance of notifying patients and offers a mechanism for local health departments to assist in partner services and further patient outreach. This structured approach not only aids in disease tracking but also enhances the overall health response within the state.

Maryland Confidential Morbidity Report Preview

MARYLAND CONFIDENTIAL MORBIDITY REPORT (DHMH 1140)

(For use by physicians and other health care providers, but not laboratories. Laboratories should use forms DHMH 1281 & DHMH 4492.)

SEND TO YOUR LOCAL HEALTH DEPARTMENT

STATE DATA BASE NUMBER (Completed by Health Department)

NAME OF PATIENT

– LAST

FIRST

DATE OF BIRTH

AGE

SEX

ETHNICITY (Select independently of RACE)

MONTH

DAY

YEAR



HISPANIC or LATINO:

YES 

NO 

UNKNOWN 



TELEPHONE NUMBERS

RACE (Select one or more. If multiracial, select all that apply)

Home:

Workplace:

American Indian/Alaskan Native 

Asian 

Black/African American 

Hawaiian/Pacific Islander 

White 

Unknown 

Other (Specify):

ADDRESS

UNIT#

CITY OR TOWN

STATE

ZIP CODE

COUNTY

OCCUPATION OR CONTACT WITH VULNERABLE PERSONS

WORKPLACE, SCHOOL, CHILD CARE FACILITY, ETC.

( Include Name, Address, ZIP Code)

(Check all that apply - include volunteers)

 HEALTH CARE WORKER (Include any PATIENT CARE, ELDER CARE, "AIDES," etc.)

 DAYCARE (Attendee or Worker)

 PARENT of a child in DAYCARE

 FOOD SERVICE WORKER

 NOT EMPLOYED

 OTHER (SPECIFY):

DISEASE OR CONDITION

DATE OF ONSET

ADMITTED

DATE ADMITTED

HOSPITAL

MONTH

DAY

YEAR

YES



MONTH

DAY

YEAR

PATIENT HAS BEEN NOTIFIED OF THIS CONDITION

YES 

NO 



CONDITION ACQUIRED IN MARYLAND

SUSPECTED SOURCE OF INFECTION

DIED

DATE DIED

PREGNANT

YES 

NO 

UNKNOWN 

YES



MONTH

DAY

YEAR

YES 

NO 

UNKNOWN 

NOT APPLICABLE 

(IF NO, INTERSTATE , or INTERNATIONAL  )



WEEKS PREGNANT __________

DUE DATE ____________________

LABORATORY TESTS - VIRAL HEPATITIS

ADDITIONAL LAB RESULTS

POS

NEG

DATE

POS

NEG

DATE

HCV Viral Genotyping

____________

DATE _____________

(SPECIMEN - TEST - RESULT - DATE - NAME of LAB)

(Please attach copies of lab reports whenever possible.)

HAV Antibody Total



_____________________

HBV surface Antibody



_____________________

ALT (SGPT) Level

______________

DATE

______________

HAV Antibody IgM



_____________________

HBV Viral DNA



_____________________

ALT – Lab Normal Range:

______________ to _____________

HBV surface Antigen



_____________________

HCV Antibody ELISA



_____________________

AST (SGOT) Level

____________

DATE _____________

HBV e Antigen



_____________________

HCV ELISA Signal/Cut Off Ratio

_____________________

AST – Lab Normal Range: ______________ to

____________

HBV core Antibody Total



_____________________

HCV Antibody RIBA



_____________________

NAME of LAB:

________________________________________

HBV core Antibody IgM



_____________________

HCV RNA (eg., by PCR)



_____________________

PERTINENT CLINICAL INFORMATION + OTHER COMMENTS

HUMAN IMMUNODEFICIENCY VIRUS (HIV) and			–	ADDITIONAL CASE INFORMATION
ACQUIRED IMMUNODEFICIENCY SYNDROME		(AIDS)	–	ADDITIONAL CASE INFORMATION
CON D IT IO NS		H IV L AB T EST S			D AT E	RESULT
WEIGHT LOSS OR DIARRHEA .............................................	CD4+	T-cells < 200 per microliter or < 14%
SECONDARY INFECTIONS (PCP, TB, etc.).........................
	ELISA
PERINATAL EXPOSURE OF NEWBORN .............................
	WESTERN BLOT
OTHER CONDITIONS ATTRIBUTED TO HIV INFECTION  (SPECIFY):
OTHER CONDITIONS ATTRIBUTED TO HIV INFECTION  (SPECIFY):	OTHER (SPECIFY):

PHYSICIAN REQUESTS LOCAL HEALTH DEPARTMENT TO ASSIST WITH: NOTIFICATION TO PATIENT YES  NO  PARTNER SERVICES YES  NO 

SEXUALLY TRANSMITTED INFECTION (STI) –						ADDITIONAL CASE INFORMATION
SYPHILIS: PRIMARY 	SECONDARY 	EARLY LATENT (LESS THAN 1 YR) 			CONGENITAL 	OTHER STAGE  (SPECIFY):

GONORRHEA: CERVICAL 	URETHRAL 	RECTAL 	PHARYNGEAL 	OPHTHALMIA NEONATORUM 		PID  OTHER  (SPECIFY):

CHLAMYDIA: CERVICAL 	URETHRAL 	RECTAL 	PHARYNGEAL 	PID 	OTHER  (SPECIFY):

OTHER STI (Specify):

STI LABORATORY CONFIRMATION AND TREATMENT

Specify STI Lab Test (e.g., RPR Titer, FTA – TPPA, Darkfield, Smear, Culture, NAAT, EIA, VDRL - CSF)

DATE

TEST

RESULT

STI Treatment Given  (Specify date – drug – dosage below)		No Treatment Given 
DATE	DRUG	DOSAGE

TUBERCULOSIS (Suspect or Confirmed) – ADDITIONAL CASE INFORMATION

MAJOR SITE: PULMONARY 

EXTRAPULMONARY 

ATYPICAL  (SPECIFY )

ABNORMAL CHEST X-RAY: 

COMMENTS:

REPORTED BY

ADDRESS

TELEPHONE NUMBER

DATE OF REPORT

MONTH DAY YEAR

Check here if completed by the Health Department

NOTES: Your local health department may contact you following this initial report to request additional disease-specific information. To print blank report forms or get more information about reporting, go to http://ideha.dhmh.maryland.gov/SitePages/what-to-report.aspx.

DHMH 1140 REVISED JANUARY 26, 2012

Click for Maryland Confidential Morbidity Report File

Form Attributes

Fact Name	Details
Purpose	The Maryland Confidential Morbidity Report is used by healthcare providers to report certain diseases and conditions.
Governing Law	This report is governed by Maryland Health-General Article, § 18-201.
Exclusions	Laboratories must use forms DHMH 1281 and DHMH 4492 instead of this report.
Patient Information	It requires detailed patient information, including name, date of birth, and ethnicity.
Health Department Role	The local health department assigns a state data base number upon receiving the report.
Notification Requirement	Providers must indicate whether the patient has been notified of their condition.
Pregnancy Status	Providers must report if the patient is pregnant and include details about the pregnancy.
Laboratory Tests	The form includes sections for reporting laboratory test results related to viral hepatitis and HIV.
Follow-Up	Health departments may contact providers for additional disease-specific information after the initial report.

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