Communicable Disease Exposure Report
Communicable Disease Exposure Report
Complete with as much detail as possible.
Name of person making this report:
Name of person making this report:
*
First
Last
Best number to reach you at:
Best number to reach you at:
*
-
###
-
###
####
The email provided will be used to communicate with you and may be shared with the County Health Department.
*
County of residence of effected person:
*
Best phone number for effected person: (Only if not listed above)
Best phone number for effected person: (Only if not listed above)
-
###
-
###
####
Center/Facility Name (Include classroom if applicable:
i.e. VS-VS1.
MO- Fiscal office
*
What type of report is this?
i.e. Hand, foot, and mouth, Scabies, COVID, Etc.
*
What type of report is this?
i.e. Hand, foot, and mouth, Scabies, COVID, Etc.
Chicken Pox
Mumps
Cold Sores (if actively “oozing” and cannot be covered by a bandage)
Pink Eye
Diphtheria
Pertussis (whooping cough)
Head Lice (live bugs or scabies)(can return once treatment begins and no visible “live bugs”)
Rubella
Hepatitis
Scabies
Impetigo
Strep throat (any strep infection)
Measles
Tuberculosis
Meningitis
COVID-19 (Follow UMHS Short-Term Exclusion and Communicable Disease Policy & Procedure for Guidance over Fever exclusion)
Hand, foot, and mouth
Other
Other
Name of child which this report is being filled out for
Name of child which this report is being filled out for
First
Last
Date of birth of child which this report is being filled out for
Date of birth of child which this report is being filled out for
/
MM
/
DD
YYYY
Is this suspected or confirmed?
i.e. at home; PCR test, etc.
*
If the child is experiencing symptoms, when did symptoms begin? (if known)
If the child is experiencing symptoms, when did symptoms begin? (if known)
/
MM
/
DD
YYYY
If experiencing symptoms, what symptoms is the person experiencing?