Source: Iowa Department of Public Health (1997).
REPORT THE FOLLOWING DISEASES IMMEDIATELY BY TELEPHONE (1-800-362-2736)
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
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: March 12, 2007
Reviewed: March 14, 2022
Revised: