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507.3E3 Reporting Form

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: