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 (5^th Disease                                                          Influenza-like illness (URI)