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_____________________________________________________________________
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DISEASE |
PATIENT |
COUNTY OR CITY |
DOB |
SEX |
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Name Parent(If Applicable)
Address
Attending Physician
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Name Parent(If Applicable)
Address
Attending Physician
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Reporting Physician, Hospital, or Other Authorized Person
Address _________________________________________________________________________________
Remarks: ________________________________________________________________________________
FOR SCHOOLS ONLY: REPORT OVER 10% ABSENT ONLY. TOTAL ENROLLMENT:
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Monday |
Tuesday |
Wednesday |
Thursday |
Friday |
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No. Absent |
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% of Enrollment |
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REPORT NUMBER OF CASES ONLY
___CHICKEN POX ____GASTROENTERITIS
___ERYTHMA INFECTIOSUM (5TH DISEASE) ____INFLUENZA-LIKE ILLNESS(URI)
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Revised/Reviewed: April 22, 2024