504.2-E4 - Disease Reporting Card

CLICK HERE TO DOWNLOAD THE DISEASE REPORTING CARD


Disease reporting is required by Iowa Administrative Code [641]-1 (139A).
To report call (800) 362-2736 or fax (515) 281-5698 or Iowa Disease Surveillance Systems (IDSS).

DISEASE AND REPORTING INFORMATION

Disease/Event: Species/Type/Group:
Specimen Source: Date Collected:
Onset Date: Date Reported to IDPH:
Epi Link?  Yes   No   Unknown Isolate to UHL?  Yes   No   Unknown
Reporter's Name: Phone:
Reporting Facility's Name:

PATIENT INFORMATION

Name (Last, First, Middle): Date of Birth:
Address: Age:
City/State/Zip/County: Gender:   M   F   Unknown
Marital Status:  Single  Married   Divorced   Widowed   Unknown Pregnant: Yes   No   Unknown
Race: White    Black/African American    American Indian/Alaska Native      Asian    Hawaiian/Pacific Islander     Other       Unknown
Ethnicity:    Hispanic/Latino      Not Hispanic/Latino  Unknown
If minor, parent/guardian name(s): Home Phone:
Work Phone: Other Phone:
Long-Term Care Facility Resident:   Yes   No   Unknown Facility Name:
Is the Case Employed:   Yes   No   Unknown Employer Name:
City: State:
In this case does the case:     Handle Food     Work in a healthcare setting        Work in a lab setting
Is the case enrolled in school or attending a childcare facility:     Yes   No   Unknown
School/Childcare Name: City:                                      State:
Hospitalized for this disease:    Yes   No Where:
Admission Date: Was death due to this disease:   Yes   No

HEALTHCARE PROVIDER AND LABORATORY INFORMATION

Name and Title of Healthcare Provider: Name of Laboratory:
Facility or Clinic: Laboratory Phone:
City and State: City and State:
Phone: Does the case have clinical symptoms:   Yes   No
Is the case lab confirmed:                           Yes  No
Comments:

Adopted: 9/98
Reviewed 7/13; 10/14; 11/17; 12/20; 10/23
Revised: 11/07
Related Policy: 504.02; 504.02-R; 504.02-E(1)-E(3)