Report a Disease Report a disease to the Sedgwick County Health Department Epidemiology Program using this form. Patient First Name (required) First Name is required. Middle Name Last Name (required) Last Name is required. Race (required) White Black/African American Asian American Indian Pacific Islander Other At least 1 Race checkbox must be selected. Other Race Ethnicity (required) Hispanic Non-Hispanic Ethnicity is required. Sex (required) Male Female Sex is required. Date of Birth Date of Birth must be between 7/2/1904 and 7/1/2024. Age Age must be between 0 and 120. Address Line 1 (required) Address Line 1 is required. Address Line 2 City (required) City is required. Postal Code (required) Postal Code is required. Please enter a valid 5- or 9-digit Postal Code. Phone Number (required) Phone Number is required. Please enter a valid 10-digit Phone Number. Occupation Parent/Guardian Mother's Name Mother's Home Phone Please enter a valid 10-digit Mother's Home Phone. Mother's Work Phone Please enter a valid 10-digit Mother's Work Phone. Mother's Cell Phone Please enter a valid 10-digit Mother's Cell Phone. Father's Name Father's Home Phone Please enter a valid 10-digit Father's Home Phone. Father's Work Phone Please enter a valid 10-digit Father's Work Phone. Father's Cell Phone Please enter a valid 10-digit Father's Cell Phone. Disease Disease Name Acquired Immune Deficiency Syndrome (AIDS) Acute flaccid myelitis Anthrax Arbroviral disease - West Nile, WEE, & SLE - indicate virus if possible in comments Babesiosis Blood lead Botulism Brucellosis Campylobacter infections Chancroid Chikungunya virus Chlamydia trachomatis genital infection Cholera Coccidioidmycosis Coronavirus Disease 2019 (COVID-19) Cryptosporidiosis Cyclospora infection Diphtheria Ehrlichiosis Escherichia coli O157:H7 (and other shiga-toxin producing E. coli, also as STEC) Giardiasis Gonorrhea Haemophilus influenzae, invasive disease Hantavirus Pulmonary Syndrome Hemolytic uremic syndrome, postdiarrheal Hepatitis A Hepatitis B Hepatitis B during pregnancy Hepatitis C Hepatitis, viral (acute and chronic) Histoplasmosis Human Immunodeficiency Virus (HIV) (includes Viral Load Tests) Legionellosis Leprosy (Hansen disease) Leptospirosis Listeriosis Lyme disease Malaria Measles (rubeola) Meningococcal Disease Mumps Other - Please state in comments Perinatal Hepatitis C Pertussis (whooping cough) Plague (Yersinia pestis) Poliovirus Psittacosis Q Fever Rabies, human and animal Rubella, including congenital rubella syndrome Salmonellosis, including typhoid fever Severe Acute Respiratory Syndrome (SARS) Shigellosis Smallpox Spongioform encephalopathy (STE) or prion disease (includes vCJD) Spotted fever rickettsiosis Streptococcal invasive, drug resistant form from Group A or pneumoniae Syphilis, including congenital syphilis Tetanus Toxic shock syndrome, streptococcal and staphylococcal Trichinosis Tuberculosis, active disease Tuberculosis, latent infection Tularemia Vaccinia, post vaccination infection or secondary transmission Varicella (chickenpox) Vibriosis (Vibrio species) Viral hemorrhagic fever West Nile Fever Yellow fever (required) Disease Name is required. Symptoms Onset Date Onset Date must be between 7/2/2019 and 7/2/2024. Diagnosis Date Diagnosis Date must be between 7/2/2019 and 7/2/2024. Treatment Description Date Treatment Prescribed Date Treatment Prescribed must be between 7/2/2019 and 7/2/2024. Hospitalized? Yes No Unknown If Yes, where? Disease Specific Immunizations and Rash Information Immunizations and Dates If rash present, rash onset date If rash present, rash onset date must be between 7/2/2019 and 7/2/2024. Varicella Rash Onset Description Severity of Rash Unknown Mild (<50 lesions) Moderate (50-500) Severe (>500) Laboratory Testing Was laboratory testing ordered? Yes No Unknown Laboratory Specimen Date Specimen Date must be between 7/2/2019 and 7/2/2024. Tests Requested Doctor/Clinic Doctor Name Clinic Name Doctor Phone Please enter a valid 10-digit Doctor Phone. Additional Information If yes to any of the following, please provide details (e.g., estimated delivery date, child care facility name and address, travel history) in the Comments field. Pregnant? Yes No Unknown School Association? Yes No Unknown Child Care Association? Yes No Unknown Adult Care Home Resident? Yes No Unknown Lives in Other Group Home? Yes No Unknown Food Handler? Yes No Unknown History of Travel? Yes No Unknown Comments School School or other reporting facility School District Cheney Clearwater Derby Goddard Haysville Maize Mulvane Renwick Valley Center Wichita Name of Person Making Report (required) Please enter your name in the Name of Person Making the Report field. Reporting Phone Number (required) Please enter your phone number in the Reporting Phone Number field. Please enter a valid 10-digit Reporting Phone Number. School Nurse (if different from person making this report) School Nurse Phone Please enter a valid 10-digit School Nurse Phone. Grade Teacher Name Last Attendance Date Last Attendance Date must be between 7/2/2022 and 7/2/2024.