FY2016Q2 - Flint Dermatology Chart Abstraction Form

Form Approved

OMB No. 0923-0051

Exp. Date 03/31/2018

Flint Dermatology Chart Abstraction Form

Investigation ID: ______ Date: ___________ Dermatologist: ______

Patient Demographics

DOB: ___ / ___ / ___ Sex: □ Male □ Female Occupation: __________________ Ethnicity: □ Hispanic □ Not Hispanic

Race: □ American Indian/ Alaskan Native □ Asian □ Black □ Native Hawaiian/ Pacific Islander □ White

History of Present Illness

Chief complaint: ____________________________________________________________________________________

Symptoms Onset Duration

________________________________ ______________ ______________

________________________________ ______________ ______________

________________________________ ______________ ______________

Diagnoses/Treatment/Recommendations

Diagnoses: _____________________________________________________________________________________

Prescription medications: _________________________________________________________________________

______________________________________________________________________________________________

Other recommendations: _________________________________________________________________________

_______________________________________________________________________________________________

_____________________________________________________________________________________________

Assessment of Relationship of Skin Condition to Water Exposure (Circle)

Definitely unrelated Possibly related Probably related Definitely related Unknown

Notes

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Public reporting burden of this collection of information is estimated to average 15 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 Reports Clearance Officer; 1600 Clifton Road NE, MS E-11 Atlanta, Georgia 30333; ATTN: PRA (0923-0051)

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