Emergency Department Surveillance Report Form

Loading...

To report information related to an increase in ED visits due to infectious diseases/disease syndromes, please call 1-800-705-8868 or FAX this form to your local health department.

Name of Hospital and Department:

 

Name and position of person filling out form:

 

Phone number of person listed above:

 

Since __________, we have seen an increase in patients presenting with the following syndromes:

 

 

Number of patients ____

Description of signs and symptoms or suspicious cases:

 

 

 

 

 

 

 

 

Emergency Department Surveillance Report Form
Last updated December 01, 2010