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Case Report Forms

These forms should ONLY be used by Local Health Department staff during a case investigation. Citizens wishing to report the occurrence of a communicable disease should consult their Local Health Department by phone. Data collected on these forms should help determine if cases meet the appropriate CDC case definitions

Disease / Condition specific forms
Anthrax Meningitis (Aseptic)
ms word logo Meningitis (Aseptic)
Babesiosis Meningitis (Bacterial)
Botulism Meningococcal Disease
Botulism Infant Mumps (Updated)
Brucellosis Outbreak (See below)
Cholera and Other Vibrio Illnesses Pediatric Severe Influenza Illness
Cryptosporidiosis Supplement Perinatal Hepatitis B
Cyclospora Perinatal Hepatitis B Contact
Data and Specimen Handling (DASH) Pertussis
Dengue Pneumonia- Health Care Worker
Diphteria Polio
Encephalitis
ms word logoEncephalitis 		Psittacosis

Escherichia coli 0157:H7

 Q-Fever
Gastroenteritis Illness Rickettsial (RMSF/Ehrlichiosis)
Haemophilus Influenzae Rocky Mountain Spotted Fever
Hansen's Disease (Leprosy) Rubella
Hantavirus Rubella - Congenital
Hepatitis (Viral) SARS
ms word logoHepatitis C (Initial) Smallpox

ms word logoHepatitis C (Supplemental)

 Tetanus

Kawasaki Syndrome Printable

 Toxic Shock Syndrome
Kawasaki Syndrome Fillable Trichinosis
Legionellosis - CDC Tularemia
Legionellosis - DHMHSupplemental Typhoid and Paratyphoid Fever
Leptospirosis Vaccine Adverse Event ReportingSystem(VAERS)
Leprosy Varicella
Listeria

Varricella Death Investigation
Lyme Disease
ms word logo Lyme Disease
 Varicella Death Guidelines
Malaria Vibrio
Measles West Nile Virus
ms word logo West Nile Virus
   

Outbreak Final Report Forms

Long-Term Care Facility Forms

Adobe
Acrobat

Microsoft
Word

Gastroenteritis Outbreak

PDF

Word

Respiratory Outbreak

PDF

Word

Scabies Outbreak

PDF

Word

Drug Resistant Organism Outbreak

PDF

Word
     
Foodborne Outbreak Forms    
     
Investigation of a Foodborne Outbreak Form PDF Word
Guidelines for Completing “Foodborne Outbreak” Form PDF Word
E coli 0157:H7 Outbreak Surveillance Report Form PDF  
     
Other Forms    
     

Daycare Facility Outbreak

PDF

Word

Hospital Outbreak (Excluding Gastroenteritis)

PDF

Word

Gastroenteritis Outbreak at a Hospital

PDF

Word

Pertussis Outbreak

PDF

Word

School Outbreak

PDF

Word

Waterborne Illness Outbreak

PDF

Word
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