[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-348144-105":3,"detail-sidebar-cat-0-en-105":81,"doc-detail-348144-en":130},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","std-11a-syphilis-case-report-form","STD-11a - Syphilis Case Report Form","","Fax report template for submitting sexually transmitted disease information to the State of New Jersey Department of Health, Sexually Transmitted Disease Program. Includes instructions that the laboratory report must be faxed together with the completed case report form and highlights required red fields. Collects patient demographics, exam reason, HIV testing and PrEP status, syphilis diagnosis stage, additional related diagnoses, laboratory results, treatment details, symptoms and onset dates, prior testing history, and reporting clinic/provider information under strict confidentiality.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/document/","Document",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/document/healthcare/","Healthcare",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/document/std-11a-syphilis-case-report-form/348144/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/std-11a-syphilis-case-report-form/348144.png","ImageObject",300,407,{"name":42,"@type":43},"supergirl","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-28","2026-09-22",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",10,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What documents must be faxed when submitting this syphilis case report form?","Question",{"text":63,"@type":64},"The laboratory report must be faxed with this case report form.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"Which fields are marked as required on the form?",{"text":68,"@type":64},"Questions colored in red are required fields and must be completed before submitting the form.",{"name":70,"@type":61,"acceptedAnswer":71},"What information does the form request for diagnosis and treatment?",{"text":72,"@type":64},"It collects the syphilis diagnosis stage, additional diagnoses, lab results, treatment dates and regimens, symptoms and symptom onset date, and patient syphilis history including prior test dates and results.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},348144,1790128068,{"code":4,"msg":82,"data":83},"success",[84,88,92,96,101,106,110,115,120,123,126],{"id":22,"doc_module":4,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},"Story & Novel",90,"story-novel",{"id":26,"doc_module":4,"doc_module_name":25,"category_name":89,"show_sort_weight":90,"slug":91},"Literature",80,"literature",{"id":33,"doc_module":4,"doc_module_name":25,"category_name":93,"show_sort_weight":94,"slug":95},"Exam",70,"exam",{"id":97,"doc_module":4,"doc_module_name":25,"category_name":98,"show_sort_weight":99,"slug":100},5,"Comic",60,"comic",{"id":102,"doc_module":4,"doc_module_name":25,"category_name":103,"show_sort_weight":104,"slug":105},6,"Technology",50,"technology",{"id":107,"doc_module":4,"doc_module_name":25,"category_name":29,"show_sort_weight":108,"slug":109},7,40,"healthcare",{"id":111,"doc_module":4,"doc_module_name":25,"category_name":112,"show_sort_weight":113,"slug":114},8,"Research & Report",30,"research-report",{"id":116,"doc_module":4,"doc_module_name":25,"category_name":117,"show_sort_weight":118,"slug":119},9,"Religion & Spirituality",20,"religion-spirituality",{"id":118,"doc_module":4,"doc_module_name":25,"category_name":121,"show_sort_weight":118,"slug":122},"World Cup","world-cup",{"id":55,"doc_module":4,"doc_module_name":25,"category_name":124,"show_sort_weight":55,"slug":125},"Lifestyle","lifestyle",{"id":127,"doc_module":4,"doc_module_name":25,"category_name":128,"show_sort_weight":97,"slug":129},19,"General","general",{"code":4,"msg":82,"data":131},{"doc_id":79,"user_id":132,"nickname":42,"user_avatar":133,"doc_module":4,"category_id":107,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":139,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":12,"update_tm":143,"read_time":30},962088121634,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","Fax Report to the STD Confidential Fax Line:  \n(609) 826-4870  \nThe State of New Jersey Department of Health  \nSexually Transmitted Disease Program  \nSYPHILIS CASE REPORT FORM PO Box 363, Trenton NJ 08625-0363 | 609-826-4869  \n**Lab Report MUST be faxed with this Case Report Form*  \nQuestions colored in red are required fields. Please ensure all required fields are complete before submitting this form.  \nPATIENT INFORMATION  \n\n| LAST NAME |  |  | FIRST NAME |  |  |  | MIDDLE INITIAL |  |  | DATE OF BIRTH |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| ADDRESS |  |  |  |  | CITY |  |  | STATE |  | ZIP CODE |\n| TELEPHONE (indicate home, work or cell) |  | SEX AT BIRTH\u003Cbr>□Male □Female |  |  | CURRENT GENDER\u003Cbr>□Male □Female |  | IS PATIENT PREGNANT?\u003Cbr>□Yes □No □Unknown |  |  | ESTIMATED DELIVERY DATE\u003Cbr>(n/a if not\u003Cbr>pregnant): |\n| ETHNICITY\u003Cbr>□Hispanic\u003Cbr>□Non-Hispanic\u003Cbr>□Unknown | RACE (Check all that apply)\u003Cbr>□White □Black □Asian\u003Cbr>□American Indian/Alaskan Native\u003Cbr>□Native Hawaiian/Other Pacific Islander\u003Cbr>□Unknown |  |  | GENDER OF SEX PARTNER(S)\u003Cbr>□Male\u003Cbr>□Female\u003Cbr>□Both\u003Cbr>□Unknown\u003Cbr>□Other: |  | REASON FOR EXAM (Check one)\u003Cbr>□Symptomatic (describe below)\u003Cbr>□Routine exam – no symptoms\u003Cbr>□Exposed to infection |  |  | DATE OF LAST HIV TEST: |  |\n|  |  |  |  |  |  |  |  |  | RESULT: □Pos □Neg □Unk\u003Cbr>IS PATIENT ON PrEP?\u003Cbr>□Yes □No □Unknown\u003Cbr>WAS PATIENT REFERRED TO PrEP?\u003Cbr>□Yes □No □Unknown |  |\n\nDIAGNOSIS  \n\n| SYPHILIS |  |\n| --- | --- |\n| DIAGNOSIS (select one):\u003Cbr>□Primary (chancre)\u003Cbr>□Secondary (rash, etc.)\u003Cbr>□Early latent (\u003C1 year duration but no symptoms)\u003Cbr>□Late latent (>1 year duration but no symptoms)\u003Cbr>□Unknown duration\u003Cbr>□Congenital\u003Cbr>ADDITIONAL DIAGNOSES (check all that apply):\u003Cbr>□Neuro syphilis □Ocular syphilis □Otic syphilis | LAB RESULTS: (*MUST include lab report with this form*) |\n|  | TREATMENT:\u003Cbr>DATE TREATED:   (check all treatments below that apply)\u003Cbr>□Bicillin 2.4mu IMx1 □ Bicillin 2.4mu IMx3wks\u003Cbr>□Other (include dosage): \u003Cbr>SYMPTOMS:\u003Cbr>SYMPTOM ONSET DATE (n/a if not pregnant) :\u003Cbr>DESCRIBE SYMPTOMS (Check all that apply):\u003Cbr>Chancre/Lesion Palmar Rash Plantar Rash Other Rash:\u003Cbr>Alopecia Other: |\n|  | PATIENT SYPHILIS HISTORY:\u003Cbr>BEFORE THESE POSITIVE RESULTS, WAS THE PATIENT EVER PREVIOUSLY TESTED FOR SYPHILIS?\u003Cbr>□ Yes □ No □ Unknown IF YES:\u003Cbr>DATE OF PREVIOUS RPR:  RESULT: □Positive □Negative TITER:  DATE OF PREVIOUS TREPONEMAL:   RESULT: □Positive □Negative |\n| COMMENTS: |  |\n| OTHER REPORTABLE STDS |  |\n| If you want to report a case of chancroid, please call 609-826-4869 to discuss further.\u003Cbr>|  |\n\n\n| REPORTING CLINIC INFORMATION |  |  |  |\n| --- | --- | --- | --- |\n| PERSON COMPLETING FORM\u003Cbr>(first) (last) | EXAMINING PROVIDER\u003Cbr>(first) (last) |  | DATE |\n| FACILITY NAME |  | TELEPHONE (direct line) |  |\n| ADDRESS\u003Cbr>(street) (city) (state) |  |  | ZIP CODE |\n\nThank you for reporting a STD. All information will be managed with the strictest confidentiality.  \nPRIVILEGED AND CONFIDENTIAL COMMUNICATION: The information contained in this message is privileged, confidential or otherwise exempt from disclosure and is intended solely for the use of the individual(s) named above. If you are not the intended recipient, you are hereby advised that any dissemination, distribution or copying of this communication is prohibited. If you have received this facsimile in error, please immediately notify the sender by telephone and destroy the original facsimile.  \nSTD-11a","cbCaihUOkR0Wt2bg","https://ap.wps.com/l/cbCaihUOkR0Wt2bg","pdf",505377,"English","# Patient Information\n## Diagnosis\n## Treatment and Symptoms\n# Reporting Clinic Information","[{\"question\":\"What documents must be faxed when submitting this syphilis case report form?\",\"answer\":\"The laboratory report must be faxed with this case report form.\"},{\"question\":\"Which fields are marked as required on the form?\",\"answer\":\"Questions colored in red are required fields and must be completed before submitting the form.\"},{\"question\":\"What information does the form request for diagnosis and treatment?\",\"answer\":\"It collects the syphilis diagnosis stage, additional diagnoses, lab results, treatment dates and regimens, symptoms and symptom onset date, and patient syphilis history including prior test dates and results.\"}]","STD-11a - Syphilis Case Report Form | PDF",1790071376]