Code No. 507.3E3 Report the Following Diseases IMMEDIATELY BY Telephone

Reporting Form

 

REPORT THE FOLLOWING DISEASES IMMEDIATELY BY TELEPHONE (1.800.362.2736)

Botulism                                  Poliomyelitis                                       Yellow Fever

Cholera                                    Rabies (Human)                                  Disease outbreaks of

Diphtheria                               Rubella                                                any public health concern

Plague                                     Rubella (Measles)

REPORT ALL OTHER DISEASES BELOW.                                         

Week Ending_____________________________________________________________________

DISEASE

PATIENT

COUNTY OR CITY

DOB

SEX

 

 

 

 

 

 

 

Name                 Parent(If Applicable)

 

 

Address

 

 

Attending Physician

 

 

 

 

 

 

 

 

 

 

 

 

Name                 Parent(If Applicable)

 

 

Address

 

 

Attending Physician

 

 

 

 

 

Reporting Physician, Hospital, or Other Authorized Person

Address _________________________________________________________________________________

Remarks: ________________________________________________________________________________

FOR SCHOOLS ONLY:  REPORT OVER 10% ABSENT ONLY.  TOTAL ENROLLMENT:

 

Monday

Tuesday

Wednesday

Thursday

Friday

No. Absent

 

 

 

 

 

% of Enrollment

 

 

 

 

 

 

REPORT NUMBER OF CASES ONLY

 

___CHICKEN POX                                                 ____GASTROENTERITIS

 

___ERYTHMA INFECTIOSUM (5TH DISEASE)         ____INFLUENZA-LIKE ILLNESS(URI)

 

 

Revised/Reviewed: April 22, 2024