507.3E3 Reporting Form

POSTED: July 26, 2024

Code No. 507.3E3 REPORTING FORM

 

Source:  Iowa Department of Public Health (1997).

REPORT THE FOLLOWING DISEASES IMMEDIATELY BY PHONE (1-800-362-2736)

 

Botulism Poliomyelitis Yellow Fever
Cholera Rabies (Human) Disease outbreaks of
Diphtheria Rubella any public health concern
Plague Rubeola (measles)
REPORT ALL OTHER DISEASES BELOW. WEEK ENDING
See other side for list of reportable infectious diseases.
DISEASE PATIENT COUNTY OR CITY DOB SEX
Name Parent (If applicable)
Address
Attending Physician
Name Parent (If applicable)
Address
Attending Physician
Name Parent (If applicable)
Address
Attending Physician
Name Parent (If applicable)
Address
Attending Physician
Name Parent (If applicable)
Address
Attending Physician

 

Reporting Physician, Hospital, or Other Authorized Person

Address
Remarks:

 

FOR SCHOOLS ONLY:  Report over 10% absent only.  Total enrollment:                                               
Monday Tuesday Wednesday Thursday Friday
No.

Absent
% of Enrollment
REPORT NUMBER OF CASES ONLY

        Chickenpox         Gastroenteritis

        Erythema infectiosum (5th Disease         Influenza-like illness (URI)

 

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