| Date of Report: The date on which the reporting party (e.g., physician, nurse practitioner, physician assistant, etc.) completes collection of minimum data for the EICR | | | |
| Report Submission Date/Time: The date and time at which the EHR system sends the EICR data to the jurisdictional public health agency or designee | | | |
| Sending Application: The name of the sending software application | | | |
| Provider ID: Identification code for the healthcare provider (e.g., NPI) | | | |
| Provider Name: The first and last name of the healthcare provider | | | |
| Provider Phone: The provider’s phone number with area code | | | |
| Provider fax: The provider’s fax number with area code | | | |
| Provider Email: The provider’s email address (for secure communication) | | | |
| Provider Facility/Office Name: The provider facility’s full name, not necessarily where care was provided to patient | | | |
| Provider Address: The geographical location or mailing address of the provider’s office or facility. Address must include street address, office or suite number (if applicable), city or town, state, and zip code | | | |
| Facility ID Number: Identification code for the facility (e.g., Facility NPI) | | | |
| Facility Name: The facility’s name where the patient received healthcare; for follow up to identify contact exposure, appropriate treatment, etc. | | | |
| Facility Type: the type of facility where the patient received or is receiving healthcare for the reportable conditions (e.g., hospital, ambulatory, urgent care, etc.) | | | |
| Facility Phone: The facility’s phone number with area code | | | |
| Facility Address: The mailing address for the facility where the patient received or is receiving healthcare for the reportable condition. Must include street address, city/town, county, state, and zip code. | | | |
| Patient ID Number: Patient medical record number, or other identifying value – something OTHER THAN Social Security Number | | | |
| Patient Name: All names for the patient, including legal names and aliases; Must include the name type (i.e., legal or alias), first name, middle name, and last name | | | |
| Parent/Guardian Name: All names for the patient’s parent or guardian, including legal names and aliases (if patient age is < 18); Must include the name type (i.e., legal or alias), first name, middle name, and last name | | | |
| Patient or Parent/Guardian Phone: All phone numbers and phone number types for the patient or parent/guardian | | | |
| Patient or Parent/Guardian Email: The email address for the patient or the patient’s parent/guardian | | | |
| Patient Street Address: All addresses for the patient, including current and residential addresses; must include street address, apartment or suite number, city or town, county, state, zip code, and country | | | |
| Birth Date: The patient’s date of birth | | | |
| Patient Sex: The patient’s biological sex (not gender) | | | |
| Race: The patient’s race | | | |
| Ethnicity: The patient’s ethnicity | | | |
| Preferred Language: The patient’s preferred language | | | |
| Occupation: The patient’s occupation (student, job title, etc.) | | | |
| Pregnant: The patient’s pregnancy status | | | |
| Visit Date/Time: Date and time of the provider’s most recent encounter with the patient regarding the reportable condition | | | |
| Admission Date/Time: Date and time when the patient was admitted to the treatment facility (e.g., hospital, clinic) | | | |
| History of Present Illness: Physician’s narrative of the history of the reportable event. Hopefully a place where information such as travel, contacts, etc. is captured | | | |
| Reason for Visit: Provider’s interpretation for the patient’s visit for the reportable event | | | |
| Date of Onset: The earliest date of symptoms for the reportable event | | | |
| Symptoms (list): List of patient symptoms (structured) for the reportable event | | | |
| Laboratory Order Code: Ordered tests for the patient during the encounter | | | |
| Placer Order Number: Identifier for the laboratory order from the encounter | | | |
| Diagnoses: The healthcare provider’s diagnoses of the patient’s health condition (all) | | | |
| Date of Diagnosis: The date of provider diagnosis | | | |
| Medications Administered (list): List of medications administered for the reportable event | | | |
| Death Date: The patient’s date of death | | | |
| Patient Class: Whether the patient is outpatient, inpatient, emergency, urgent care, etc. | | | |
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