Preparedness Home PageEmergency PreparednessAgroterrorismBioterrorismChemical EmergenciesFloodsHeat PrecautionsHurricanesPandemic FluRadiological EmergenciesTornadoesWildfiresDisaster-Related Health ThreatsDisaster Behavioral HealthInformation for ProfessionalsClinical Information on Illnesses

Emergency Department Surveillance Report Form


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