Series 500
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Policy Title: Infectious Diseases Reporting Form |
Code No. 506.4E3 |
REPORTING FORM
REPORT THE FOLLOWING DISEASES IMMEDIATELY BY TELEPHONE (1-800-362-2736)
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Botulism Cholera Diphtheria Plague |
Poliomyelitis Rabies (Human) Rubella Rubeola (measles) |
Yellow Fever Disease outbreaks of any public health concern |
WEEK ENDING ______________
REPORT ALL OTHER DISEASES BELOW.
See 507.3E2 for list of reportable infectious diseases.
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DISEASE |
PATIENT |
COUNTY OR CITY |
DOB |
SEX |
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Name of Parent (if applicable) |
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Address |
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Attending Physician |
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Name of Parent (if applicable) |
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Address |
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Attending Physician |
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Name of Parent (if applicable) |
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Address |
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Attending Physician |
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Name of Parent (if applicable) |
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Address |
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Attending Physician |
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Name of Parent (if applicable) |
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Address |
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Attending Physician |
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Reporting Physician, Hospital, or Other Authorized Person
________________________________________________________________________________________________________
Address
________________________________________________________________________________________________________
Remarks:
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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
________Chickenpox __________Gastroenteritis
________Erythema infectiosum (5th Disease) __________Influenza-like illness (URI) |
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Approved: |
Reviewed: 5/13/13; 6/10/19 |
Revised: |
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Approved: Reviewed: 5/13/13; 6/10/19 Revised: