Fillable KANSAS VARICELLA (CHICKENPOX) REPORTING FORM (Kansas Department of Health and Environment)

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KANSAS VARICELLA (CHICKENPOX) REPORTING FORM (Kansas Department of Health and Environment)

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KANSAS VARICELLA (CHICKENPOX) REPORTING FORM
Fax this form to your local health department or KDHE: 877-427-7318
Please include varicella laboratory results, if available
To report urgent diseases, call the KDHE Epidemiology Hotline: 877-427-7317
This form is available at: www.kdheks.gov/epi/disease_reporting.html
(Page 1 of 2)
(Revised 05/2018)
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: Grade/Room:
D
ISEASE OR CONDITION INFORMATION
Has the patient/guardian been notified of varicella diagnosis?
Hospitalized? Died?
Has any laboratory testing been performed?
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 #:
P
LEASE CONTINUE TO PAGE TWO FOR SUPPLEMENTAL INFORMATION FOR REPORTING VARICELLA
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
Yes (enter below) No
KANSAS VARICELLA (CHICKENPOX) REPORTING FORM
Fax this form to your local health department or KDHE: 877-427-7318
Please include varicella laboratory results, if available
To report urgent diseases, call the KDHE Epidemiology Hotline: 877-427-7317
This form is available at: www.kdheks.gov/epi/disease_reporting.html
(Page 2 of 2)
(Revised 05/2018)
S
UPPLEMENTAL VARICELLA INFORMATION – CLINICAL SYMPTOMS
Rash onset date: Number of lesions:
Rash location:
Description and characteristic of rash (select all that apply):
Patient febrile:
Patient immunocompromised:
S
UPPLEMENTAL VARICELLA INFORMATION – VACCINATION STATUS
Has patient previously received any varicella-containing vaccine?
Vaccine One:
Date received: Type:
Manufacturer: Lot Number:
Vaccine Two:
Date received: Type:
Manufacturer: Lot Number:
If unimmunized (or under-immunized), please select reason(s) below:
P
LEASE FAX THIS FORM TO YOUR LOCAL HEALTH DEPARTMENT OR KDHE AT 877-427-7318
Generalized Focal Unknown
Yes (enter below) No Unknown
Medical contraindication Religious exemption Parental objection Alternative immunization schedule
Philosophical objection
Under age for vaccination (younger than 2 months)
Unknown/other
<50 50-249 250-500
>500
Mostly macular/papular Mostly vesicular Hemorrhagic Pruritic (Itchy)
Resolved (crusted)
Crops/waves
Other:
Yes (Highest temp. °F/C) No Unknown
Yes (Describe: ) No Unknown
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KANSAS VARICELLA (CHICKENPOX) REPORTING FORM (Kansas Department of Health and Environment)

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Completed 14 August 2020

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