Sedgwick County Health Department...Working for you

Sedgwick County Health Department Epidemiology Program
1900 E. 9th Street  |  Wichita, KS 67214  |  Tel: (316) 660-7300
Disease Reporting Hot Line (316) 660-5555
Fax: (316) 660-5550

Notifiable Disease Form
**Items in red are required

 School or other reporting facility:    School District:    
 Name of person making report:    Reporting Phone Number:   (xxx-xxx-xxxx)

 Patient Information
 Name:    First:  Middle:   Last:  
 Race:            (Select all that apply)
 Date of Birth:  (mm/dd/yyyy)  Age: 
 House Number:   Primary Direction:   Street Name:  
 Street Type:   Secondary Direction:    Apt./Lot/Unit Number:  
 City:    Zip Code:   Phone Number:  (xxx-xxx-xxxx)

 Parents (Guardian) Information (If applicable)
 Home Phone:  (xxx-xxx-xxxx)  Work Phone:  (xxx-xxx-xxxx)  Cell:  (xxx-xxx-xxxx)
 Home Phone:  (xxx-xxx-xxxx)  Work Phone:  (xxx-xxx-xxxx) Cell:  (xxx-xxx-xxxx)

 Disease Name: 
 Doctor name:    Clinic name:  
 Doctor or clinic phone number:   (xxx-xxx-xxxx)
 Onset Date:  (mm/dd/yyyy)  Diagnosis Date:    (mm/dd/yyyy)
 Treatment:    Date Prescribed:   (mm/dd/yyyy)
 If Yes, where?

 Disease Specific Immunizations
 Immunizations Name:  
 Immunizations Dates:  
 For Varicella: Rash Onset:  
 Severity of Rash: 

 Additional Information
 Was laboratory testing ordered?      
 If testing was ordered: Laboratory:     Date of Specimen:   (mm/dd/yyyy)
 Tests Requested:  
 If yes to any of the following, please provide details (e.g., estimated delivery date, daycare address, travel history) in comments section.
 School association?      
 Daycare association?      
 Adult care home resident?      
 Lives in other group home?      
 Food handler?      
 History of travel?      

 School Specific Information
 Grade:    Teacher:  
 Last Attendance Date:    (mm/dd/yyyy)
 School Nurse (if different from person making this report): 
 School Nurse Phone:    (xxx-xxx-xxxx)