Communicable Disease Reporting Form - Dutchess County Government

Reporter Information

Reporting Individual *

Telephone *

Address *

Address 2

City *

State *

Zip *

Reporting Source *

Provider Name

Provider Telephone

Testing Laboratory

Laboratory Telephone

Patient Information

Patient's Name *

Patient's Alias

Patient's Guardian's Name

DOB *

Age

Country of Birth *

Primary Phone *

Home Mobile Work

Secondary Phone

Home Mobile Work

Physical Address

Address *

Address 2

City *

State *

Zip *

County *

Mailing Address (If Different Than Physical Address...)

Address

Address 2

City

State

Zip

County

Occupation (works at) *

Setting (resides/attends) *

Gender *

Pregnant? *

Race

Ethnicity

Is Patient Alive? * Date of Death

Disease *

Date of First Symptom

Date of Test

Site of Infection

Date of Diagnosis

Was Patient Notified? *

Yes No Unknown

Hospitalized? *

Name of Hospital

Medical Record Number

Admission Date

Discharge Date

Comments

Municipal Information

Related Information

Elementary & Secondary Education

Higher Education

Adult Education

Other Educational Resources & Information

Business

Community

Tourism

Arts & Leisure