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)