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

Code No. 507.3E3
                                   
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:  June 29, 2015