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:
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Name and position of person filling out form:
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Phone number of person listed above:
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Since __________, we have seen an increase in patients presenting with the following syndromes:
Number of patients ____
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Description of signs and symptoms or suspicious cases:
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Emergency Department Surveillance Report Form