Source: Iowa Department of Public Health (1997).
REPORT THE FOLLOWING DISEASES IMMEDIATELY BY TELEPHONE (1-800-362-2736)
Botulism Yellow Fever
Poliomyelitis Cholera
Rabies (Human) Disease outbreaks of Diphtheria
Rubella Plague
Rubeola (measles) any public health concern
REPORT ALL OTHER DISEASES BELOW.
See 507.3E2 for list of reportable infectious diseases.
WEEK ENDING ______________
___________________________ __________________________________ _____________________________ _________ ______
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 _______________________________________________________________________________________________
Reporting Physician, Hospital, or Other Authorized Person: ______________________________________________________________
Address: _______________________________________________________________________________________________________
Remarks:________________________________________________________________________________________________________
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FOR SCHOOLS ONLY: Report over 10% absent only.
Total enrollment:
Monday Tuesday Wednesday Thursday Friday
Number Absent ______ ______ ______ ______ ______
% of Enrollment ______ ______ ______ ______ ______
REPORT NUMBER OF CASES ONLY
Chickenpox Gastroenteritis
Erythema infectiosum (5th Disease) Influenza-like illness (URI)
