Fillable KANSAS REPORTABLE DISEASE FORM (Kansas Department of Health and Environment)

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KANSAS REPORTABLE DISEASE FORM (Kansas Department of Health and Environment)

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KANSAS REPORTABLE DISEASE FORM
Fax this form to your local health department or KDHE: 877-427-7318
Please include disease-specific laboratory results, if available
To report urgent diseases, call the KDHE Epidemiology Hotline: 877-427-7317
This form is available at: http://www.kdheks.gov/epi/disease_reporting.html
(Revised July 2018)
Today’s date:
PATIENT INFORMATION
Name:
Last First Middle
Mobile phone: Home phone:
Residential address:
City: State: Zip:
Date of Birth (if unknown, provide age):
Race: Ethnicity: Sex:
Associated with high-risk setting or institution?
Name and city of high-risk setting or institution:
D
ISEASE OR CONDITION INFORMATION
Disease or condition suspected:
Symptom onset date:
Hospitalized? Died?
Laboratory name: Specimen collection date:
Test(s) performed: Test result(s):
FACILITY AND PHYSICIAN INFORMATION
Facility name: Facility city:
Physician name: Phone #:
Name of person reporting: Phone #:
T
REATMENT INFORMATION
Treated?
White
Black
Asian
American Indian / Alaska Native
Native Hawaiian / Pacific Islander
Hispanic
Non-Hispanic
Male
Female
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Pregnant?
Daycare Health Care Food Handler School
Nursing Home Correctional Shelter Other
Yes
No
Unknown
Treatment type, dosage, start date, and duration:
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KANSAS REPORTABLE DISEASE FORM (Kansas Department of Health and Environment)

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Completed 14 August 2020

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