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506.4E3 Infectious Diseases Reporting Form

Series 500

Policy Title: Infectious Diseases Reporting Form

Code No. 506.4E3

REPORTING FORM

REPORT THE FOLLOWING DISEASES IMMEDIATELY BY TELEPHONE (1-800-362-2736)

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.

DISEASE

PATIENT

COUNTY OR CITY

DOB

SEX

 

Name of Parent (if applicable)

 

 

 

 

Address

 

 

 

 

Attending Physician

 

 

 

 

Name of Parent (if applicable)

 

 

 

 

Address

 

 

 

 

Attending Physician

 

 

 

 

Name of Parent (if applicable)

 

 

 

 

Address

 

 

 

 

Attending Physician

 

 

 

 

Name of Parent (if applicable)

 

 

 

 

Address

 

 

 

 

Attending Physician

 

 

 

 

Name of 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

 

________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: