Attachment 4 0920 0004 Change Request 9 22 08
HABISS Monthly Reporting Form
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Name of State Agency:
Name of Person Submitting Report:
Date of Submission:
Please fill out the cases entered this month. Use a “0” or “Don’t Know” when necessary. Do not leave any blanks. Please submit this report each month to Rebecca LePrell by e-mail ([email protected]) or fax, 770-488-3450.
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Sum (#) of New Cases Entered |
Sum (#) of Historical Cases Entered |
Human Illness Confirmed |
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Human Illness Suspect |
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Non HAB-related Human Illness |
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Sum (#) of New Cases Entered |
Sum (#) of Historical Cases Entered |
Animal Illness Confirmed |
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Animal Illness Suspect |
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Non HAB-related Human Illness |
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Name of HAB- Illness Investigated |
# of New Cases Entered (By Illness) |
# of Historical Cases Entered (By Illness) |
Anatoxin-a Poisoning |
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Anatoxin-a(s) Poisoning |
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Azaspiracid Poisoning (AZP) |
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Brevetoxin Poisoning from Aerosols in Humans |
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Brevetoxin Poisoning From Ingestion in Humans: Neurotoxic shellfish poisoning (NSP) |
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Brevetoxin Poisoning From Ingestion in Animals: Food Web |
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Brevetoxin Poisoning From Skin Contact (direct dermal and mucous membranes) |
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Ciguatera Fish Poisoning |
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Cylindrospermopsin Poisoning |
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Diarrhetic shellfish poisoning (DSP) From Ingestion in Humans |
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Domoic Acid Poisoning From Ingestion in Humans (Amnesic shellfish poisoning ASP) |
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Domoic Acid Poisoning From Food Web in Animals |
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Lyngbyatoxin Poisoning |
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Microcystin Poisoning |
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Nodularin Poisoning |
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Palytoxin Poisoning From Ingestion in Humans |
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Saxitoxin Poisoning From Ingestion in Humans (Paralytic shellfish poisoning) |
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Saxitoxin Poisoning From Food Web in Animals |
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Pectenotoxin Poisoning |
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Tetrodotoxin Poisoning (pufferfish or fugu poisoning) |
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Yessotoxin Poisoning |
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Public reporting burden for this collection of information is
estimated to average 30 minutes
per
response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information. An
agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a
currently valid OMB control number. Send comments regarding this
burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to:
CDC/ATSDR Information Collection Review Office; 1600 Clifton Road
NE, M.S. D-74; Atlanta, Ga. 30333; ATTN: Paperwork Reduction Act
Project (0920-0004)
| File Type | application/msword |
| File Title | Attachment 4 0920 0004 Change Request 0920 0004 9 18 08 |
| Author | bas1 |
| Last Modified By | bas1 |
| File Modified | 2008-09-22 |
| File Created | 2008-09-22 |