Office of Infectious Disease Services

Infectious Diseases Reporting & Investigation Forms

Other Report Forms
Form Title Form Description Revised
Communicable Disease Report Communicable Disease Report Form (ADHS) 04/2014
Laboratory Report Form to Report Reportable Laboratory Conditions (ADHS) 08/2011
Outbreak- Disease Report Forms and Related Documents
Form Title Form Description Revised
Outbreak Report Outbreak Summary Form (ADHS) 05/2011
Foodborne Outbreak Investigation of a Foodborne Outbreak Form (CDC) 10/2000
Waterborne Disease Outbreak Waterborne Diseases Outbreak Report Form (CDC) 11/1999
Disease Specific Forms
Disease Report within Disease Investigation Forms Revised
Amebiasis 5 working days Amebiasis Investigation Form (ADHS)   5/2006
Anthrax 24 hours Anthrax Case Report Form (ADHS)  05/2010
Basidiobolomycosis 5 working days Basidiobolomycosis Questionnaire (ADHS) 03/2009
Botulism 24 hours Botulism Adult Investigation form  (ADHS)
Botulism Infant Investigation form (ADHS) 
06/2010
06/2010
Brucellosis 1 working day Brucellosis Case Investigation form (ADHS)  06/2010
Campylobacteriosis 5 working days Campylobacteriosis investigation Form (ADHS)  
Chagas   Chagas Case Investigation Form (ADHS) 06/2010
Chancroid 5 working days Communicable Disease Report (ADHS) 06/2009
Chlamydia 5 working days Communicable Disease Report (ADHS) 06/2009
Cholera 1 working day Cholera and Other Vibrio Illness Surveillance Report (CDC) 07/2000
Coccidioidomycosis (Valley Fever) 5 working days    
Conjunctivitis 24 hours if outbreak    
Creutzfeldt-Jakob disease (CJD) 5 working days Creutzfeldt-Jakob Disease Investigation Form (ADHS) 10/2008
Cryptosporidiosis 5 working days Cryptosporidiosis Investigation Form (ADHS)  
Cyclosporiasis 5 working days    
Cysticercosis 5 working days    
Dengue 5 working days Dengue Case Investigation Report Form (CDC) 11/2006
Diarrhea, nausea, or vomiting 24 hours if outbreak    
Diptheria 24 hours    
Ehrlichiosis 5 working days Tick-Borne Rickettsial Disease Case Report Form (CDC) 02/2011
Emerging or exotic disease 24 hours    
Encephalitis 1 working day    
Enterohemorrhagic and Enterotoxigenic Escherchia coli 24 hours Enterohemorrhagic E.coli (Shiga-toxin producing) and/or HUS Investigation Form (ADHS) 01/2010
Free-living Ameba 1 working day Free-living Ameba Case Report Form 01/27/12
Gastroenteritis, viral 24 hours if outbreak Suspected Viral Gastroenteritis Outbreak Form (ADHS) 04/2008
Giardiasis 5 working days Giardiasis Investigation Form (ADHS) 11/2003
Gonorrhea 5 working days Communicable Disease Report (ADHS) 06/2009
Haemophilus influenzae 5 working days Haemophilus influenzae Investigation Form (ADHS) 12/2010
Hansen’s disease (Leprosy) 5 working days Hansen's Disease (Leprosy) Investigation Form (ADHS) 03/2010
Hantavirus 5 working days Hantavirus Pulmonary Syndrome Case Report Form (CDC)  
Hemolytic uremic syndrome (HUS) 24 hours Enterohemorrhagic E. coli (Shiga-toxin producing) and/or HUS Investigation Form (ADHS)  01/2010
Hepatitis A 5 working days Hepatitis A Case Report (ADHS)  
Hepatitis B & and D 5 working days Acute Hepatitis B and D Case Report Form (ADHS)
Chronic Hepatitis B and D Case Report Form (ADHS)
 
Hepatitis C 5 working days Acute Hepatitis C Case Report Form (ADHS)
Chronic Hepatitis C Case Report Form (ADHS)
 
Hepatitis E 5 working days    
Herpes 5 working days Communicable Disease Report (ADHS) 06/2009
Human Immunodeficiency Virus (HIV) 5 working days Communicable Disease Report (ADHS) 06/2009
Influenza 1 working day if pediatric death Influenza-Associated Pediatric Deaths Case Report Form (CDC) 10/2013
  Novel Influenza A Case Report Form (CDC) 07/2013
Kawasaki Syndrome 5 working days Kawasaki Syndrome Investigation Form (ADHS) 05/2010
Legionellosis (Legionnaires’ disease) 5 working days Legionellosis Investigation Form (ADHS)  06/2010
Leptospirosis 5 working days Leptospirosis Case Investigation Report Form (CDC)  10/1987
Listeriosis 24 hours Listerosis Investigation Form (ADHS) 08/2003
Lyme disease 5 working days Lyme Disease Investigation Report Package (ADHS) 11/2009
Lymphocytic choriomeningitis (LCMV) 5 working days    
Malaria 5 working days Malaria Case Surveillance Report Form (CDC) 05/2011
Measles (Rubeola) 24 hours Measles Surveillance Worksheet Form (CDC)  
Meningitis (Bacterial) 24 hours Meningococcal Investigation Form (ADHS) 03/2011
Methicillin-resistant Staphylococcus aureus (MRSA) 5 working days Methicillin-Resistant Staphylococcus aureus (MRSA) Surveillance Supplemental Form (ADHS)  12/2004
Mumps 1 working day Mumps Surveillance Worksheet Form (CDC)  01/2008
Norovirus 24 hours if outbreak Suspected Viral Gastroenteritis Outbreak Form (ADHS) 03/2003
Pertussis (whooping cough) 24 hours Pertussis Investigation Form (ADHS) 12/2010
Plague 24 hours Plague Investigation Form CDC  06/2002
Poliomyelitis 24 hours Suspected Polio Case Worksheet Form (CDC)  
Psittacosis 5 working days Psittacosis Case Surveillance Report Form (CDC)  03/1981
Q fever 1 working day Q-Fever Case Report Form (CDC)  03/2002
Rabies 24 hours Animal Bite or Exposure Report Form (ADHS) 08/2004
Rash Illness   Rash Illness Investigation Form (ADHS)  
Respiratory Syncytial virus (RSV)      
Reye syndrome 5 working days    
Rocky Mountain spotted fever 5 working days Tick-Borne Rickettsial Disease Case Report Form (CDC) 02/2011
Rubella (German Measles) 1 working day Rubella Surveillance Worksheet Form (CDC)
Congenital Rubella Syndrome Case Report Form (CDC) 
02/2009
Salmonellosis 5 working days Salmonellosis Investigation Form (ADHS)  06/2010
Scabies 24 hours if outbreak    
Severe acute respiratory distress syndrome (SARS) 24 hours    
Shigellosis 5 working days Shigellosis Investigation Form (ADHS)  
Smallpox 24 hours Smallpox Response Plan + Forms (CDC)  
Streptococcal Group A 5 working days Invasive Group A Streptococcus Surveillance Supplemental Form (ADHS)  
Streptococcal Group B 5 working days    
Streptococcus pneumoniae 5 working days Streptococcus pneumoniae Surveillance Worksheet Form (CDC)  
Syphilis 5 working days Communicable Disease Report (ADHS) 06/2009
Taeniasis 5 working days    
Tetanus 5 working days Tetanus Surveillance Worksheet Form (CDC)  
Tick-borne Relapsing Fever (TBRF) 5 working days    
Toxic Shock Syndrome 5 working days Toxic Shock Syndrome Case Report Form (CDC)  04/1996
Trichinosis 5 working days    
Tuberculosis 1 working day Report of Verified Case of Tuberculosis Form (CDC)
RVCT Addendum Form for TB Reporting (ADHS)
Prevention Registry Form (ADHS)
Interjurisdictional Tuberculosis Notification (ADHS)
Interjurisdictional Follow-up Form (ADHS)
11/2010
11/2003
Tularemia 24 hours    
Typhoid fever 24 hours Typhoid and Paratyphoid Fever Surveillance Report Form (CDC) 02/2011
Typhus fever 1 working day    
Unexplained death 24 hours Unexplained Death Case Report Form (ADHS)  09/2008
Vaccinia-related adverse event 1 working day    
Vancomycin-resistant Staphylococcus aureus (VRSA) 24 hours Vancomycin-resistant Staphylococcus aureus (VRSA) 11/2010
Vancomycin-intermediate Staphylococcus aureus (VISA) 24 hours Vancomycin-intermediate Staphylococcus aureus (VISA) 11/2010
Vancomycin-resistant Staphylococcus epidermidis (VRSE) 24 hours Vancomycin-resistant Staphylococcus epidermidis (VRSE) 11/2010
Varicella (Chickenpox) 5 working days 05/2005

05/2010
Vibrio 5 working days Cholera & Other Vibrio Illness Surveillance Report Form (CDC)  01/2006
Viral Hemorrhagic Fevers 24 hours    
West Nile Virus (WNV) 5 working days West Nile Virus Case Investigation Form (ADHS) 06/2011
Yellow fever 24 hours    
Yersiniosis 5 working days Yersiniosis Investigation Form (ADHS) 08/2006

Note: Many forms provided in PDF format.