507.3E3 - Reporting Form

Source:  Iowa Department of Public Health (1994).

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

Botulism                                                      Poliomyelitis                Yellow Fever

Cholera                                                        Rabies(Human)          Disease outbreak of any public health concern

Diphtheria                                                    Rubella         

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

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)

 

 

Approved    4/11/05                        
Reviewed  11/15/21                       
Revised  11/11/13