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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 1, 2010