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.
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Attending Physician
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Attending Physician
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Attending Physician
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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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No. Absent |
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REPORT NUMBER OF CASES ONLY __________ Chickenpox __________ Gastroenteritis __________ Erythema infectiosum ( 5th disease) __________ influenza-like illness (URI)
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Approved 4/11/05
Reviewed 11/15/21
Revised 11/11/13
