507.3E3 - REPORTING FORM

Botulism

Poliomyelitis

Yellow Fever

Cholera

Rabies (Human)

Disease outbreaks of

Diphtheria

Rubella

    any public health concern

Plague

Rubeola (measles)

REPORT ALL OTHER DISEASES BELOW.

WEEK ENDING

See other side for list of reportable infectious diseases.

DISEASE

PATIENT

COUNTY OR CITY

DOB

SEX

Name    Parent (If applicable)

Address

Attending Physician

Name    Parent (If applicable)

Address

Attending Physician

Name    Parent (If applicable)

Address

Attending Physician

Name    Parent (If applicable)

Address

Attending Physician

Name    Parent (If applicable)

Address

Attending Physician

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)