Sedgwick County Health Department...Working for you

Sedgwick County Health Department Epidemiology Section
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

(For School Reporting Use Only) School District:   School:

Patient Information:
Name:  First: Middle:  Last:
Race:
Ethnicity:   Sex: 
Date of Birth: (mm/dd/yyyy)

Address:
House Number:Primary Direction:Street Name:
Street Type:Secondary Direction: Apt./Lot/Unit Number:
City: Zip Code:Phone Number:

Parents (Guardian) Information (If applicable):
Mother:
Home Phone: Work Phone: Cell:
Father:
Home Phone: Work Phone: Cell:

Disease:
Name:
Doctor:  Doctor Phone Number:
Symptoms:
Onset Date:
Treatment:  Date Prescribed:

Disease Specific Immunizations: (For School Reporting Use Only)
Immunizations Name:
Immunizations Dates:
For Varicella: Rash Onset:
Severity of Rash:

Additional Information: (For School Reporting Use Only) 
Grade:  Teacher:
Last Attendance Date:
School Nurse: Phone:
Laboratory: Date of Speciman:
Tests Requested:
Comments:

Name of Person Making Report:   Phone Number: