Code No. 507.3E3
REPORTING FORM
Source: Iowa Department of Public Health (1997)
REPORT THE FOLLOWING DISEASES IMMEDIATELY BY TELEPHONE (1.800.362.2736)
Botulism Poliomyelitis Yellow Fever
Cholera Rabies Disease outbreaks of any public Diphtheria Rubella health concern
Plague Rubeola (Measles)
REPORT ALL OTHER DISEASES BELOW. WEEK ENDING________________
See 507.3E2 for a list of reportable infectious diseases.
Disease _______________________________________
Patient _______________________________________
County or City _______________________________________
Date of Birth _______________________________________
Gender _______________________________________
Name of Parent _______________________________________
Address _______________________________________
Attending Physician _______________________________________
Reporting Physician, Hospital, or Other Authorized Person
Name _______________________________________
Address _______________________________________
Remarks ____________________________________________________________________________
____________________________________________________________________________
_____________________________________________________________________________________________
Revised (02/2017)
