Report a Disease

Report a disease to the Sedgwick County Health Department Epidemiology Program using this form.

Patient
(required)
(required)







(required)
(required)
(required)
(required)
Parent/Guardian
Disease
(required)


Disease Specific Immunizations and Rash Information
Varicella



Laboratory Testing


Doctor/Clinic
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.














School
(required)
(required)