Report a Disease Report a disease to the Sedgwick County Health Department Epidemiology Program using this form. Patient First Name (required) Middle Name Last Name (required) Race (required)WhiteBlack/African AmericanAsianAmerican IndianPacific IslanderOther Other Race Ethnicity (required)HispanicNon-Hispanic Sex (required)MaleFemale Date of Birth Age Address Line 1 (required) Address Line 2 City (required) Postal Code (required) Phone Number (required) Occupation Parent/Guardian Mother's Name Mother's Home Phone Mother's Work Phone Mother's Cell Phone Father's Name Father's Home Phone Father's Work Phone 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) Symptoms Onset Date Diagnosis Date Treatment Description Date Treatment Prescribed Hospitalized?YesNoUnknown If Yes, where? Disease Specific Immunizations and Rash Information Immunizations and Dates If rash present, rash onset date Varicella Rash Onset Description Severity of RashUnknownMild (<50 lesions)Moderate (50-500)Severe (>500) Laboratory Testing Was laboratory testing ordered?YesNoUnknown Laboratory Specimen Date Tests Requested Doctor/Clinic Doctor Name Clinic Name 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?YesNoUnknown School Association?YesNoUnknown Child Care Association?YesNoUnknown Adult Care Home Resident?YesNoUnknown Lives in Other Group Home?YesNoUnknown Food Handler?YesNoUnknown History of Travel?YesNoUnknown 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) Reporting Phone Number (required) School Nurse (if different from person making this report) School Nurse Phone Grade Teacher Name Last Attendance Date