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Report a Disease

Patient

First Name *First Name is required.

Middle Name

Last Name *Last Name is required.

Race *

White

Black/African American

Asian

American Indian

Pacific Islander

Other

At least 1 Race checkbox must be selected.

Other Race

Ethnicity *

Hispanic

Non-Hispanic

Ethnicity is required.

Sex *

Male

Female

Sex is required.

Date of BirthDate of Birth must be between 7/1/1905 and 6/30/2025.Please enter a valid date in M/d/yyyy format

AgeAge must be between 0 and 120.

Address Line 1 *Address Line 1 is required.

Address Line 2

City *City is required.

Postal Code *Postal Code is required.Please enter a valid Postal Code.

Phone Number *Phone Number is required.Please enter a valid Phone Number.

Occupation

Parent/Guardian

Mother's Name

Mother's Home PhonePlease enter a valid Mother's Home Phone.

Mother's Work PhonePlease enter a valid Mother's Work Phone.

Mother's Cell PhonePlease enter a valid Mother's Cell Phone.

Father's Name

Father's Home PhonePlease enter a valid Father's Home Phone.

Father's Work PhonePlease enter a valid Father's Work Phone.

Father's Cell PhonePlease enter a valid Father's Cell Phone.

Disease

Disease Name *Disease Name is required.

Symptoms

Onset DateOnset Date must be between 7/1/2020 and 7/1/2025.Please enter a valid date in M/d/yyyy format

Diagnosis DateDiagnosis Date must be between 7/1/2020 and 7/1/2025.Please enter a valid date in M/d/yyyy format

Treatment Description

Date Treatment PrescribedDate Treatment Prescribed must be between 7/1/2020 and 7/1/2025.Please enter a valid date in M/d/yyyy format

Hospitalized?

Yes

No

Unknown

If Yes, where?

Disease Specific Immunizations and Rash Information

Immunizations and Dates

If rash present, rash onset dateIf rash present, rash onset date must be between 7/1/2020 and 7/1/2025.Please enter a valid date in M/d/yyyy format

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 DateSpecimen Date must be between 7/1/2020 and 7/1/2025.Please enter a valid date in M/d/yyyy format

Tests Requested

Doctor/Clinic

Doctor Name

Clinic Name

Doctor PhonePlease enter a valid 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

Name of Person Making Report *Please enter your name in the Name of Person Making the Report field.

Reporting Phone Number *Please enter your phone number in the Reporting Phone Number field.Please enter a valid Reporting Phone Number.

School Nurse (if different from person making this report)

School Nurse PhonePlease enter a valid School Nurse Phone.

Grade

Teacher Name

Last Attendance DateLast Attendance Date must be between 7/1/2023 and 7/1/2025.Please enter a valid date in M/d/yyyy format

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